The Power of Partnership: Achieving Success with Compassion

Summary Proceedings

Twenty-Second Annual Trachoma Control Program Review

ThePowerofPartnership:Achieving

SuccesswithCompassion

Atlanta, Georgia

March 22-23, 2021

Acknowledgments

The Carter Center’s Trachoma Control Program would like to acknowledge the support of numerous partners and donors who have made the 2020 activities reviewed in this document possible:

Abbott

Alwaleed Philanthropies

Bill & Melinda Gates Foundation

Conrad N. Hilton Foundation

Crown Agents

The END Fund

Expanded Special Project for Elimination of Neglect Tropical Diseases (ESPEN)

The Francis I. Proctor Foundation at the University of California at San Francisco

International Trachoma Initiative (ITI)

IZUMI Foundation

The John and Kathleen Schreiber

Foundation

Lions Clubs International Foundation

Lions Clubs of Ethiopia and the late Hon. World Laureate, Dr. Tebebe Y.

Berhan

Lions Clubs of Mali

Lions Clubs of Niger

Manaaki Foundation

Margaret A. Cargill Philanthropies

Noor Dubai Foundation

The OPEC Fund for International Development (OFID)

Pfizer Inc.

Sightsavers

SoapBox Soaps

Government of the Republic of Sudan

The Task Force for Global Health/

Neglected Tropical Diseases Support Center (NTDSC)

United Kingdom Foreign,

Commonwealth, and Development Office (FCDO)

University of North Carolina – Chapel

Hill

The William H. Donner Foundation, Inc.

World Health Organization (WHO)

World Innovation Summit for Health (WISH)

And to many others who may not be listed, our sincere gratitude.

Acknowledging The Power of Partnership The Carter Center’s Trachoma Control Program celebrated another year of achievements despite the many challenges brought forth by the coronavirus disease 2019 (COVID-19) global pandemic. Through the power of partnership, compassion, and resilience, we assisted in providing life-altering surgeries, mass drug administration (MDA), and community health education across Ethiopia, Mali, Niger, South Sudan, and Sudan. The Carter Center is proud to assist, in partnership, the most mature and long-standing trachoma programs worldwide. These programs have historically been the largest of their type, contributing to some of the most outstanding global SAFE (Surgery, Antibiotics, Facial cleanliness, and Environmental improvement) outputs annually and cumulatively. In the World Health Organization (WHO) Weekly Epidemiological Record, published 24 July 2020, global 2019 data showed The Carter Center’s Trachoma Control Program assisted in 15.7% of the worldwide output of MDA and 24% of all trachomatous trichiasis (TT) surgeries performed. Additionally, 44% of all surgeries worldwide were conducted in Ethiopia, with The Carter Center assisting 39% of all TT surgeries in Ethiopia.

The Power of Partnership starts with those we serve and those we collaborate most closely with, specifically the communities and the ministeries of health in each country. The Carter Center has been in partnership since 1999 in Mali, Niger, and Sudan; and since 2001 in Ethiopia and South Sudan. The community and ministerial partnerships form the foundational elements of our collective achievements and serve as powerful bonds to work together towards our common goals to eliminate trachoma as a public health problem as well as ‘build hope’. Since 1999, The Carter Center’s Trachoma Control Program, in partnership with those we serve, has provided TT surgeries to 859,376 persons and assisted in the distribution of more than 210 million doses of antibiotics. The Center’s partnerships have also contributed to health education programs and activities in more than 85,000 schools within more than 90,000 communities. These outcomes reflect a tremendous cumulative success as the Carter Center-assisted countries, through the Power of Partnership, edge closer to achieving elimination thresholds.

The Carter Center’s work and the achievements of the parternships would not be possible year after year without the critical support and committed advocacy of additional partners, such as the generosity and enthusiasm of donors, including Pfizer Inc., Conrad N. Hilton Foundation, Lions Clubs International Foundation, Noor Dubai Foundation, Alwaleed Philanthropies, The OPEC Fund for International Development, Abbott, Manaaki Foundation, Crown Agents/ASCEND, Bill & Melinda Gates Foundation, Margaret A. Cargill Philanthropies, The END Fund, The John and Kathleen Schreiber Foundation, The William H. Donner Foundation, Inc., and many others. Moreover, we would also like to acknowledge and thank our crucial and dedicated academic partners who continue to support academic research and laboratory work to advance the Center’s mission to control the world's leading cause of infectious blindness.

Table of Contents

Acronyms 1

Executive Summary 2

Trachoma Control Country Program Summaries

SAFE in Ethiopia 5

SAFE in Amhara, Ethiopia 10

Destination Elimination, 20 Years of Trachoma Programming in Mali 16

SAFE in Niger 22

SAFE in South Sudan 26

SAFE in Sudan 31

Summary Tables & Figures

Table 1: Summary of National Data from Trachoma Control Programs, Carter Center-Assisted Countries 35

Table 2: National Trachoma Control Program Annual Targets 2021, Carter Center-Assisted Countries 36

Table 3: Carter Center-Assisted Implementation of SAFE, Carter Center-Assisted Outputs 37

Table 4: Carter Center-Assisted Implementation of SAFE (1999-2020) 38

Figure 1: Persons Operated for TT, Carter Center-Assisted Countries 39

Figure 2: Azithromycin Distribution, Carter Center-Assisted Countries 40

Figure 3: Health Education, Carter Center-Assisted Countries 41

Special Sessions

Persistent and Recrudescent TF: Patterns and Programmatic Implications

42

Persistent Trachoma: What Have We Learned? Lessons From Amhara, Ethiopia

44

Genomics of Ocular Chlamydia trachomatis After 5 Years of SAFE Interventions for Trachoma in Amhara, Ethiopia 45

South Sudan: A Face Washing Qualitative Study

46

Health Campaign Effectiveness Coalition - Overview

48

Literature Review of Photography As An Imaging Tool for Trachoma

50

Photographic Grading for Trachoma Diagnosis Within Trachoma Impact Surveys: A Study in Amhara Region,

Ethiopia

52

International Coalition for Trachoma Control (ICTC) Updates

53

Compassion and Interconnectedness in Public Health

57

Appendix Materials

Appendix I: 2021 Trachoma Control Program Review Recommendations 59

Appendix II: Trachoma: The Disease 61

Appendix III: TT and TF Thresholds for Disease Elimination

62

Appendix IV: Trachoma Control Program Review Agenda 63

Appendix V: List of Participants 65

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Acronyms ARHB Amhara Regional Health Bureau

ARRET Azithromycin Reduction to Reach Elimination of Trachoma

AVENIR Azithromycine Pour la Vie Des Enfants au Niger - Implémentation et Recherche

(Azithromycin For the Lives of Children in Niger - Implementation and Research)

CDC Centers for Disease Control and Prevention

COVID-19 Coronavirus Disease 2019

Ct Chlamydia trachomatis DBS Dried blood spots

ESPEN Expanded Special Project for Elimination of Neglected Tropical Diseases

FCDO United Kingdom Foreign, Commonwealth, and Development Office

FMOH Federal Ministry of Health

GET2020 Alliance WHO Alliance for the Global Elimination of Trachoma by 2020

GSM4 WHO Fourth Global Scientific Meeting

GTMP Global Trachoma Mapping Project

GWEP Guinea Worm Eradication Program

HCEC Health Campaign Effectiveness Coalition

ICTC International Coalition for Trachoma Control

IECW Integrated Eye Care Worker

ITI International Trachoma Initiative

MDA Mass Drug Administration

MOH Ministry of Health

NGO Non-Governmental Organization

NNN NTD NGO Network

NTD Neglected Tropical Diseases

NTDSC Neglected Tropical Diseases Support Center

NTTF National Trachoma Task Force

PC-NTDs Preventive Chemotherapy – Neglected Tropical Diseases

PESS Post-Elimination Surveillance Survey

PNLC Programme National de Lutte contre la Cecité (National Blindness Prevention Program)

PNSO Programme National de Santé Oculaire (National Eye Health Program)

PPE Personal Protective Equipment

RAMA Risk Assessment and Mitigation Action

SAFE Surgery (S), Antibiotics (A), Facial Cleanliness (F), and Environmental Improvement (E)

SLR Single-Lens Reflex

SOP Standard Operations Procedures

STP School Trachoma Program

TAP Trachoma Action Plan

TEO Tetracycline Eye Ointment

TFGH The Task Force for Global Health

TIS Trachoma Impact Surveys

TSS Trachoma Surveillance Surveys

TF Trachomatous Inflammation-Follicular

TI Trachomatous Inflammation-Intense

TT Trachomatous Trichiasis

UNICEF United Nations Children’s Fund (formerly United Nations Children’s Education Fund)

WASH Water, Sanitation, and Hygiene

WGS Whole Genomic Sequencing

WHA World Health Assembly

WHO World Health Organization

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Executive Summary The 22nd Annual Trachoma Control Program Review was held as a virtual conference from March 22-23, 2021, due to the global COVID-19 pandemic. To celebrate the partnership and resilience through this trying period worldwide, the theme of this year’s review was “The Power of Partnership: Achieving Success with Compassion.” Attending this year’s review were representatives from the Ministries of Health and Carter Center offices in the five countries where the Center currently provides assistance: Ethiopia, Mali, Niger, South Sudan, and Sudan. Partners and donors in attendance included representatives from Abbott, CBM International, Crown Agents, Emory University, The END Fund, FHI360, The John and Kathleen Schreiber Foundation, Johns Hopkins University, Health and Effectiveness Coalition, Helen Keller International, Conrad N. Hilton Foundation, International Coalition for Trachoma Control (ICTC), International Trachoma Initiative (ITI), Lions Clubs International Foundation, London School of Hygiene and Tropical Medicine, Noor Dubai Foundation, Neglected Tropical Diseases Support Center (NTDSC), Pfizer Inc., The Francis I. Proctor Foundation at the University of California at San Francisco, Rollins School of Public Health at Emory University, RTI International, Sightsavers, The Task Force for Global Health (TFGH), University of California – Los Angeles, University of North Carolina – Chapel Hill, University of Pennsylvania, United Nations Children’s Fund (UNICEF), U.S. Agency for International Development, U.S. Centers for Disease Control and Prevention (CDC), and WHO.

In keeping tradition with past program reviews, the 2021 program review provided an opportunity to assess the status of each national program and discuss the progress toward meeting the elimination of trachoma as a public health problem. On April 1, 2020, due to COVID-19, the WHO issued guidance that limited SAFE programmatic activities at the community level. On July 27, 2020, the WHO issues further guidance for the resumption of community activities, noting special precautions to decrease the risk of transmission of COVID-19. Additionally, different limitations were in place in each country, which understandably limited activities. With the assistance of partners like The Carter Center, the national programs developed and implemented a risk assessment and mitigation action (RAMA) tool and new standard operations procedures (SOP) to assess and mitigate risks and prepare for the safe resumption of programmatic activities. During the suspension of mass campaign activities, the Center supported ministries of health in select COVID-19 response activities. In Ethiopia, the Center provided logistical support for the COVID-19 Taskforce and assisted the Amhara Regional Health Bureau (ARHB) in the distribution of COVID-19 related supplies. In Niger, The Carter Center supported the National Program to pivot trachoma health education messaging via radio broadcasts to COVID-19 prevention messages, as well as provided the Program and regional directorates personal protective equipment (PPE), hand sanitizers and sanitizing equipment, handwashing stations, and soap. In South Sudan and Sudan, The Carter Center assisted in distributing supplies, developing communication materials, and adapting health messages to integrate hygiene and preventive COVID-19 messages into trachoma and Guinea worm communications.

Despite COVID-19, the Carter Center-assisted Programs were highly productive. In 2020, a total of 8,274 TT surgeries were conducted, 68.5% of which were provided to women; more than 700,000 doses of antibiotics were distributed, and F&E interventions continued in communities and schools. In the Amhara region in Ethiopia, 32 prevalence surveys were conducted in 2020, results of which show significant progress toward elimination since 2015. The Mali National Program continues to edge closer to completing all necessary activities to finalize their elimination dossier. The Niger National Program follows closely behind, with just over 6,000 estimated TT cases remaining at the end of 2020 and 15 districts ready for impact surveys. In South Sudan, all five MDAs planned for 2020 were completed, three of which were the fifth of five needed rounds. In Sudan, a second required round of MDA and a second surgical campaign were completed in South Sudanese refugee camps. In 2020, the Neglected Tropical Diseases (NTD) Non-Governmental Organization (NGO)

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Network Conflict and Humanitarian Emergency Cross-Cutting Group, with significant Carter Center support, utilized the experiences of Sudan to develop a Resource Guide for Conflict and Humanitarian Emergencies.

The two-day review focused on successes in the face of a year of adversities. The Program Review opened with The Carter Center’s Board Chair, Mr. Jason Carter, Chief Executive Officer, Ms. Paige Alexander, and Vice President of Health Programs, Dr. Kashef Ijaz welcoming the participants, leading the participants in a moment of silence, and conveying goodwill. The moment of silence acknowledged our collective human trauma of the past year not only due to the COVID-19 global pandemic but also the pandemic of systemic racial injustice in the United States of America and issues of inequity across the globe. This compassionate recognition of the difficulties of the past year was followed by another goodwill message from Dr. Tedros Adhanom Ghebreyesus, Director-General of the WHO.

In her opening remarks, Ms. Kelly Callahan, The Carter Center’s Trachoma Control Program Director, referenced a quote by President Carter, “We must adjust to changing times and still hold to unchanging principles.” Although 2020 was a time of substantial change, our principles of hope, compassion, and interconnectedness have not changed. We must compassionately see ourselves in each other and stay focused on eliminating trachoma as a worldwide public health problem. The Carter Center and its partners have seen incredible successes and have shared as well as learned much from each other throughout the years. As such, The Carter Center remains proud and honored to assist the ministries of health on the road toward trachoma elimination as a public health problem and will continue to support this crucial work in the years to come. It has been a challenging year globally, and although the years to come might still present further difficulties, we must fight adversity together with compassion and hope for a better future.

Ms. Callahan marked the loss of two “trachoma giants” in 2020 during her presentation. Dr. Julius Schachter, known as “Julie,” died on December 20, 2020. Dr. Schachter was a microbiologist and dedicated his career of 55 years to the control of trachoma. He is credited for making the leap to consider treating the entire community, whether they were infected with trachoma or not – and thus, in some minds, established the practice of MDA. He was an ardent supporter of the global elimination of trachoma as a public health problem and was the one and only keynote speaker in 21 years of Trachoma Control Program Reviews. Ms. Callahan noted she would fondly remember his unabashed joy, passion, and dedication; he exemplified unchanging principles in his and our work. May his soul rest in the success of our collective efforts. On February 20, 2021, we lost The Honorable World Laureate Lion, Dr. Tebebe Yemane Berhan. Dr. Tebebe was not only one of the loudest voices in the fight to eliminate trachoma as a public health problem but one of the most active “doers” in the fight as well. Ms. Callahan noted she could say so many things to express her personal and the collective grief in the loss of a leader, an advocate, friend, partner, and mentor; however, she preferred the words of President Carter: “my faith demands that I do whatever I can, wherever I can, whenever I can, for as long as I can, with whatever I have to try to make a difference.” Lion Dr. Tebebe embodied this way of life to the fullest – he did whatever he could, whenever he could, with whatever he had to make a difference, to improve lives, and to end suffering. Lion Dr. Tebebe gave all he had to the fullest. May his soul rest in peace, knowing he made a difference.

Ms. Callahan was followed by Ms. Kenya Casey, The Carter Center’s Overseas Operations Senior Associate Director, leading all participants in guided mindfulness meditation. The trauma of the past year and our need for collective compassion made a mindful mediation to open the Program Review necessary. It offered the participants a moment to reflect on the power of partnership and a moment to celebrate the joys of our collective success.

Dr. Mwelecele Ntuli Malecela, NTD Director, Department of Control of NTDs, WHO, presented an overview on “Ending The Neglect To Attain The Sustainable Development Goals: A Road Map For Neglected Tropical Diseases 2021–

2030”. This strategic document and advocacy tool is focused on strengthening the programmatic responses to

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NTDs through shared goals and disease-specific targets. Dr. Malecela also gave a brief update on the current COVID-19 situation.

The Program Review then included a series of presentations over the two-day period highlighting the status, successes, and challenges in the five Carter Center-assisted countries, including a focus on the Amhara region of Ethiopia. The country-specific presentations were interspersed with multiple presentations illustrating how The Carter Center and partners remain resolute in mitigating country-specific and global program challenges. Dr. Jeremiah Ngondi of RTI International, Dr. Harry Pickering of the University of California – Los Angeles, and Carter Center Trachoma Control Program Epidemiologist, Dr. Scott Nash, presented a combined focus on ‘persistent’ trachoma findings and the need to use the existing SAFE strategy coupled with data-driven enhancements and adaptations to improve and accelerate trachoma elimination. Dr. Angelia Sanders presented an innovative approach using social marketing in a qualitative face washing study in South Sudan. Dr. Jeremy Keenan of Francis I. Proctor Foundation presented some results of the ongoing Amhara region study focused on the impact of water, sanitation, and hygiene (WASH) on trachoma. The results were not encouraging towards improved WASH in the short-to-medium-term. The participants were, however, left hopeful that with more time, the longer-term results will show improved outcomes towards trachoma elimination.

Dr. Kristin Saarlas, Director of the Health Campaign Effectiveness Coalition of TFGH, gave the participants an overview of the work of the Coalition and opportunities to engage. This was followed by Dr. Fahd Naufal of Johns Hopkins University and Ms. Cassidy Whitson, former Carter Center Trachoma Control Program student intern and now of the CDC, providing a combined session on the use of photography in the global trachoma program. Ms. Julie Jenson, Director of Corporate Social Responsibility of Pfizer Inc., provided an update on the status of Pfizer’s ongoing commitment to the global trachoma elimination program. This was followed by Dr. Paul Emerson of the ITI of TFGH providing an update as to the global status of the donation program and ITI’s commitment to improving processes and responding to the immediate needs of the programs. Mr. Scott McPherson of RTI International and the outgoing Chair of ICTC rounded out the updates with a presentation focused on current membership and strategic planning goals. Mr. McPherson noted the ICTC strategic alignment with the NTD Road Map presented by Dr. Malecela of WHO.

Dr. David Addiss, Director of the Focus Area for Compassion and Ethics of TFGH, made an impassioned presentation on the importance of compassion and ethics within global public health. Dr. Addiss used President Carter as an example of the use of compassion in all our affairs. This presentation aligned beautifully with the Program Review theme and provided a well-rounded perspective on the use of compassion, especially in partnership. Dr. Kashef Ijaz provided a focused summary on the Program Review and the success exemplified through the Power of our Partnership. Dr. Ijaz closed the 2021 Program Review and bid participants continued success in the fight to eliminate trachoma as a public health problem.

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SAFE in Ethiopia

Presented by Mr. Fikre Seife, National Neglected Tropical Diseases (NTD) Program Coordinator,

Ministry of Health (MOH) – Ethiopia

Background

The National Survey on Blindness, Low Vision, and Trachoma conducted in 2006 revealed that 2.8 million people in Ethiopia had low vision, and 1.2 million people were blind. It was estimated that 87% of blindness was from avoidable diseases. The survey revealed that active trachoma was endemic in virtually all country regions, with more than 1.3 million people living with TT. Current estimates show that 50% of the world’s trachoma burden is found in Ethiopia.

Ethiopia has shown great dedication to addressing the trachoma burden in the country, among other NTDs. The Fast Track Initiative, launched in 2015, aimed to clear the TT backlog across Ethiopia, and since its inception 628,484 TT cases have been managed. The Ethiopia NTD Master Plan was first launched in 2013, subsequently updated in 2016, and most recently revised in 2020 with an increased focus on the integration of WASH and NTD programming through the promotion of sector coordination, capacity building, and improving WASH-NTD strategies and tools. The National Program continues to be dedicated to eliminating trachoma as a public health problem by 2030.

Major Milestones in Ethiopia’s Trachoma Elimination Program

2001: National Steering Committee established 2002: Azithromycin was registered in the country 2003: Trachoma Control Program launched SAFE interventions in three districts 2006: National Survey on Blindness, Low Vision, and Trachoma conducted 2007-2010: Trachoma baseline mapping conducted in the Amhara Regional State 2013-2014: Global Trachoma Mapping Project (GTMP) completed in 672 districts (locally called woredas) 2014: Scale-up of Trachoma Elimination Program 2015: Fast Track Initiative launched by the Ministry of Health (MOH) to clear TT surgery backlog 2020: Impact survey showed 192 districts fell below 5% trachomatous inflammation-follicular (TF) and stopped

MDA activities

Surgery (S)

As of 2020, 115 previously endemic districts in Ethiopia have achieved the threshold for the elimination of TT as a public health problem (prevalence of TT <0.2%, unknown to the health system, in individuals 15 years and above). The remaining 600 districts continue to be endemic for TT, with an estimated 319,000 TT cases to operate to achieve the elimination threshold. In 2020, 20,961 people received TT surgery in Ethiopia, bringing the total number of TT surgeries conducted since the Fast Track TT initiative launched in 2015 to 628,484. These efforts to clear the surgery backlog in Ethiopia have shown great impact; from 2015 to 2020, the national estimated TT prevalence drastically reduced from 4% to 0.82%.

Antibiotic Therapy (A)

The TF prevalence has shown a great downward trend toward the threshold for the elimination of trachoma as a health problem. Baseline estimates showed that 341 districts had a TF prevalence of ≥30% (considered hyperendemic), and only 58 districts were found to be below the 5% elimination threshold. In 2020 only 206 districts had a TF prevalence of ≥30% and 250 were found to be below the 5% elimination threshold. From 2015 to 2020, the mean national estimated TF prevalence dropped from 26.6% to 13.3%. The number of antibiotic doses distributed in Ethiopia has significantly increased over time; since 2010, 361 million doses have been distributed. However, due to the global COVID-19 pandemic, in 2020, MDA was completed in only two

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regions: Southern Nations, Nationalities, and Peoples’ and Somali; the estimated ten million doses distributed in 120 districts constituted 16.1% of the expected geographic coverage in 2020. Despite the challenges the program faced, the districts are showing progress; based on the most recent impact surveys conducted in 2020, a total of 135 districts are no longer hyperendemic, and more than 190 districts have fallen below the 5% TF prevalence threshold, no longer requiring MDA.

Facial Cleanliness (F) & Environmental Improvement (E)

The National Program continues to remain focused on F&E as part of its NTD program and has enhanced its focus through each of the three NTD Master Plans from 2013 to 2021. In 2021, the most current NTD Master Plan was devised to clearly articulate the relevance of WASH-NTD integration, promote sector coordination toward a common goal, and improve the utilization of WASH-NTD strategies and tools. To support these efforts, the MOH of Ethiopia has developed a set of toolkits and guidelines for the implementation of the WASH-NTD strategies: Woreda Level Coordination Toolkit for WASH and NTD Sectors and Health Communication

Message Guide. These documents are important tools for decision-making and technical implementation at regional, zonal, and district levels.

The Program plans to increase engagement and collaboration with WASH partners; technical working groups have been established at the national and regional levels. The working groups work to bring together WASH and NTD partners to have an even greater impact on trachoma throughout Ethiopia. Additionally, the National Program published a landscape analysis that works on mapping where WASH and NTD partners are operating throughout the country. The purpose of the landscape analysis is to create a framework of program quality standards to achieve national and international targets, facilitate coordination and integration, and enhance the targeted WASH interventions to improve health outcomes. Mapping will continue to look at access to water and other indicators that could impact how effective WASH activities may be on eliminating trachoma and other NTDs. The National Program’s priority is to make the WASH-NTD coordination a standard operation for all stakeholders and support them in the implementation process.

COVID-19 Impact and Mitigation Measures

The global COVID-19 pandemic greatly impacted the National Trachoma Program; suspension of activities resulted in delays and decreased outputs of MDA, surveys, and surgery. In response to the pandemic, the MOH, in collaboration with partners and stakeholders, developed a risk assessment checklist and mitigation tool to reduce the risk of COVID-19 transmission during implementation. Additionally, SOP were developed for all outreach activities (MDA, surveys, and TT surgical training and outreach). To mitigate the risk associated with COVID-19 transmission, MDA will shift modalities from the community-based approach to house-to-house; these activities will take longer to complete, increasing the operational costs related to MDA. Further, the procurement of PPE and the longer drug storage, due to the delay in MDA will result in increased programmatic expenses and a lack of available storage space in central national warehouses.

Programmatic Challenges

In addition to the impact of COVID-19 on national activities, the Program faced several additional challenges in 2020:

• There remains a high number of estimated TT cases unknown to the national health system as well as an estimated 15% post-operative TT, according to 2020 survey results.

• Current quality assurance systems are weak, and post-operative follow-up for TT surgeries is challenging in all regions.

• In some areas, the Program has poor integration of TT surgical services into the primary healthcare service due to a lack of TT surgical kits and a high turnover of integrated eye care workers (IECWs) at

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health centers. • Some districts are struggling to achieve (or stay below) the 5% elimination threshold for TF—45% of

the districts at surveillance survey have come back above the elimination threshold.

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Ethiopia – TF Prevalence: Children 1-9 years

Figure 2 – Estimated prevalence of TF in 2020: 13.3%

2020

Figure 1 – Estimated prevalence of TF in 2015: 26.6%

2015

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Ethiopia – TT Prevalence: Adults ≥ 15 years

2020

Figure 4 – Estimated prevalence of TT in 2020: 0.82% Figure 3 – Estimated prevalence of TT in 2015: 4%

2015

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SAFE in Amhara, Ethiopia

Presented by Dr. Hiwot Debebe, Deputy Head, Amhara Regional Health Bureau (AHRB)

Background

In the Amhara region of Ethiopia, a trachoma prevalence survey at the zonal level was conducted in 2007 to quantify the zonal prevalence of active trachoma and TT; based on the results, all zones in the Amhara region were eligible for the full SAFE strategy and an estimated 643,904 people required surgery to correct TT. Since 2001, the ARHB has been working with The Carter Center to implement the full SAFE strategy, completing more than 715,000 surgeries and distributing more than 186 million doses of antibiotics.

As of March 2020, 48 out of 166 districts in the Amhara region reached the elimination threshold for TF and are exempt from MDA. Unfortunately, due to the COVID-19 pandemic, the regional trachoma program could not conduct MDA activities in 2020. However, after conducting the appropriate risk assessments, the ARHB developed new SOP that will continue to enable the resumption of SAFE activities. The Program remains focused on reaching the elimination of trachoma as a public health problem by intensifying TT outreach, better understanding the remaining backlog, and assessing alternative strategies for persistent districts.

Table 1. Program Achievements in 2020

Indicator Goal Amhara Region

(Carter Center-Assisted) Target Achieved

# of persons operated 158,042 33,872 7,132 (21%) # of women operated 4,869 (68%) # of surgeons trained 23 12 (52%)

Doses of Zithromax® distributed during MDA 15,310,025 15,310,025 -

Doses of tetracycline distributed during MDA* 312,449 312,449 - # of villages with health education 3,447 3,447 (100%) % improved latrine coverage 44% 36.3%

*Due to the COVID-19 pandemic, no MDA was conducted in the calendar year 2020. MDA in Amhara will be conducted in early 2021 and, if completed by June 2021, will be counted against the program year 2020.

Surgery (S)

In 2020, 7,132 people received TT surgery across the Amhara region; of those operated, 4,869 (68%) were women. Since the beginning of the program in 2001, 715,259 TT surgeries have been conducted in Amhara. Baseline surveys completed in 2007 showed an estimated backlog of more than 600,000 TT cases to operate to reach the elimination target. As of the end of 2020, it is estimated that 150,441 individuals require TT surgical services to clear the backlog. Although limited surgeries were completed in 2020, as a result of the suspension of activities due to COVID-19, surgical outreach activities restarted in November 2020. Additionally, the program was also able to support the training of 12 new TT surgeons, known locally as IECWs, and retraining of 24 existing IECWs who will help continue the work to clear the TT backlog in Amhara.


By the end of 2020, 48 of the 166 districts in the Amhara region, with an estimated population of 4,782,895, have achieved the elimination target for TF and no longer require MDA; this includes 33 districts that remained below the elimination threshold at surveillance survey. This achievement shows great progress throughout the region compared to just five years prior, when only nine districts were below 5% TF. For the 118 districts with

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TF greater than 5%, MDA activities could not be completed in 2020 due to the global COVID-19 pandemic. MDA activities will resume in 2021, and the Amhara region aims to “catch up” from the delay by conducting two rounds of MDA, where possible, in 2021. To mitigate the risk of COVID-19 transmission during MDA, SOP have been developed for MDA implementation, which will be completed using a house-to-house strategy rather than the standard community-based, central point distribution modality.

Despite the delays due to COVID-19, the Program completed surveys in 32 districts in 2020. Of the completed surveys, nine were trachoma surveillance surveys (TSS). The results of the TSS highlighted a challenge that has been observed in Amhara as well as throughout Ethiopia—of the nine surveyed districts, only two remained below the 5% threshold, with the remaining seven districts coming back above the 5% TF threshold, which would result in re-enrollment in MDA. More work is needed to better understand these districts and determine if the results from TSS show true recrudescence or if this could just be related to statistical variability.


In 2020, the program remained focused on implementing F&E activities through health education activities in the community and in schools. A total of 3,447 villages received health education in 2020, and the School Trachoma Program (STP) was implemented in 8,741 schools. In January and February 2020, 8,029 teachers and principals were trained in West Amhara, training activities that had remained from 2019, when East Amhara teachers and principals were trained. Due to the success of the STP in primary schools, the ARHB and The Carter Center, in collaboration with the Amhara Bureau of Education, are developing a pre-school level curriculum, which will be implemented in 2021.


As a result of the COVID-19 pandemic, most program activities were suspended in April 2020 and began resuming implementation in October/November 2020. In an effort to mitigate the risk of COVID-19 transmission during outreach activities, the ARHB implemented a RAMA tool before each activity and developed SOP for each of the outreach activities (MDA, surveys, TT case finding, and surgery). During outreach, risk mitigation strategies included daily temperature checks for outreach teams, consistent use of PPE, and COVID-19 screening questions before eye exams. As a result of the new risk mitigation strategies, which also included limiting vehicle capacity during outreach to allow for social distancing and the change in MDA modality, programmatic costs will increase.


In addition to COVID-19 related challenges, insecurity in some parts of the region affected program implementation and caused the internal displacement of the population. Additionally, the high rate of districts returning with TF prevalence above the 5% threshold at surveillance survey, and thus must be re-enrolled in MDA activities, greatly impacts the Program; alternative strategies to address these districts may need to be considered.

Program Plans for 2021

Surgery (S)

• Operate 30,532 TT cases • Train 28 new IECWs • Retrain 88 IECWs

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• Distribute 22,484,131 doses of Zithromax® • Distribute 454,772 doses of tetracycline eye ointment (TEO)


• Conduct health education in 3,447 villages • Implement and supervise the STP in primary schools

Surveys

• Conduct 70 trachoma impact surveys (TIS) and eight TSS

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Amhara, Ethiopia – TT Prevalence: Adults ≥ 15 years

2015

Figure 1 Figure 2

2020

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Amhara, Ethiopia – TF Prevalence: Children 1-9 years

2015

Figure 3 Figure 4

2020

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Amhara, Ethiopia – MDA Plans, 2021

Figure 5 – The map for 2021 planned MDA activities include MDA originally planned for 2020 and MDA originally planned for 2021. If required and timing permits, two rounds of MDA will be conducted in calendar year 2021 to catch up from the delays resulting from COVID-19.

Amhara, Ethiopia – Survey Plans, 2021

Figure 6 – The map for 2021 planned survey activities include surveys originally planned for 2020 and surveys originally planned for 2021. If required and timing permits, two surveys will be conducted in calendar year 2021 to catch up from the delays resulting from COVID-19. To create the projections, it was assumed that districts would decrease by one prevalence category at each survey round—for those districts with TF prevalence of 10-29.9% prior to survey, it was assumed they would return a result of 5-9.9% TF, resulting in one more round of MDA followed by another TIS.

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Destination Elimination, 20 Years of Trachoma Programming in Mali

Presented by Professor Lamine Traoré, National Coordinator, Programme National de Santé Oculaire (PNSO), Ministry of Health (MOH) – Mali

Background

Following prevalence surveys conducted in 1996-1997, trachoma was identified as a major public health issue in Mali, including an estimated 85,000 persons with TT that required surgery. The Programme National de Santé Oculaire (PNSO) established the national trachoma control program in 1999 and initiated TT surgical services to address this issue. Two years later, in 2001, MDA activities commenced in Mali, followed by F&E activities in 2003. By the end of 2016, all districts in Mali had reached the elimination threshold for TF, and no further MDA was required. As a result, Mali now must only achieve the threshold for the elimination of TT as a public health problem; by 2020, only five districts remain, with an estimated 597 TT cases to achieve this goal. The National Program has made tremendous progress since 1999 and hopes to achieve elimination in 2021. However, insecurity remains the greatest challenge and limits the Program’s access to districts with the remaining TT patients.

Key Milestones and Progress toward Elimination

1996-1997: National baseline prevalence survey 1999: National Trachoma Control Program launched 2003-2005: Facial cleanliness and Environmental improvement activities initiated 2005-2020: Impact and surveillance surveys conducted 2014-2019: National Program adopts the ratissage strategy as TT case management policy 2018: Creation of the Dossier Committee 2020: Transition planning activities in place 2021: Target date for elimination of trachoma in Mali

Table 1. Program Achievements, 1999-2020

Indicator National Program Carter Center-Assisted

# of persons operated 89,533 30,983* # of women operated 53,731 18,595** # of surgeons trained 179 30 # of surgeons retrained 105 20 Doses of Zithromax® distributed during MDA 29,126,964 698,083 Doses of tetracycline distributed during MDA 582,539 120,795

# of villages with health education 7,576 3,959 # of household latrines built 155,686 117,086

# masons trained 7,775 *Support began in 2008 **The Carter Center started reporting on the number of women operated in 2012

Reaching Elimination over Time

The National Program has made tremendous progress towards the elimination of trachoma as a public health problem. The 1996 baseline survey in Mali revealed that 75% of districts surveyed were endemic for trachoma, which equated to an estimated 85,000 TT people in need of surgery and an estimated 2.2 million people at risk of blindness due to trachoma. Mali began MDA in 2001, and by 2016, Mali conducted its final MDA as all

17

districts had reached the TF threshold for elimination of trachoma as a public health problem. From 1999 through 2020, the National Program conducted 89,533 TT surgeries, 30,983 of which were assisted by The Carter Center. The Program has noted that women received 60% of surgical services overall. A total of 179 TT surgeons were trained, and 105 surgeons received refresher training. By the end of 2020, an estimated 597 persons remain to be operated. The total number of persons may be fewer if anecdotal evidence observed during ratissage, or house-to-house case finding, (see below) remains true; fewer cases tend to be found than are estimated using survey data.

Ratissage

The National Program has implemented the ratissage strategy since 2014 to locate and operate on the remaining TT cases in the country. Prior to this, TT patients received surgery during TT camps and at community health centers. With time, it became difficult to locate the remaining cases using these methods. Therefore the Program moved to ratissage, moving house-to-house, screening everyone 15 years and above to identify TT cases and offer surgical services on site. All information related to screening, TT case confirmation, and surgeries is documented. The information is used by the Program to determine if “mop-up” activities are required in select areas; the Program aims to achieve 80% coverage of the target population. The ratissage approach in several areas of Mali, combined with data and experience from several other countries, revealed TIS were perhaps overestimating the number of TT patients remaining. In November 2018, due to the challenges programs were reporting related to the potential overestimation of TT, it was determined by the WHO Fourth Global Scientific Meeting (GSM4) that data from case finding, or ratissage, could be used in place of survey data to demonstrate that a district has addressed the TT burden in a district. Previously, only surveillance survey results could be used to demonstrate the achievement of both TF and TT thresholds for elimination. As such, the ratissage data from at least nine different districts will be used in Mali to demonstrate that the TT burden has been addressed. Though ratissage is necessary in select districts and has shown success in identifying the remaining cases, the ratissage strategy is time-consuming and costly. The strategy is also challenging to implement in certain areas due to insecurity and potential distrust of community members toward outsiders. During the COVID-19 pandemic, the National Program, with the support of The Carter Center, implemented the RAMA tool and established SOP to conduct ratissage and surveys in the remaining districts.

Transition Planning and Dossier Development

In collaboration with its partners, the National Program is currently collating relevant information to establish a program profile to better understand the services available and required to address the post-elimination needs. Some major components of this programmatic profile include the designation of referral clinics or hospitals for TT surgery, as the number of incident cases will be minimal; the number of trained surgeons for TT surgery and the plan for ongoing refresher training; the number of trained nurses for TT diagnosis and referral; the estimated number of consumables required; the plan for future financing for incident cases; and opportunities for collaboration with the WASH sector.

Work on Mali’s dossier is well underway. In 2018, a task force was established to coordinate work on the dossier, and both the data and narrative portions of the dossier are in process. The National Committee for the Validation of the Elimination of Trachoma as a Public Health Problem in Mali was established and has held meetings to review the data and narrative draft documents.

As Mali is nearing its goal of elimination of trachoma as a public problem, some key challenges and lessons learned have been included for the benefit of programs that have yet to reach this stage. Long before programs near the elimination thresholds, programs should begin the transition plan as well as establish a plan for dossier development. Programs must also demonstrate good collaboration and coordination between partners and sectors and recognize the need to be flexible and adapt to challenges. Though programs must adapt to changing situations, it is also necessary to acknowledge that some issues, like insecurity, cannot be controlled; programs

18

should be aware that insecurity in just one district could prevent the entire country from finalizing the dossier for the validation of the elimination of trachoma as a public health problem.

Activities Remaining in 2021 to Achieve Elimination

Before Mali can submit the elimination dossier, hopefully in 2021, some key activities must be completed. The districts of Douentza and Koro (Mopti), Tominian (Segou), Koutiala (Sikasso), and Tombouctou (Tombouctou) must complete surveys and/or ratissage to demonstrate that the district has fulfilled the requirements for the elimination of trachoma as a public health problem. However, security has been a challenge for the National Program for many years, and some of these districts currently remain inaccessible. While some areas are currently restricted due to insecurity, the Program continues to establish the transition plan and complete the dossier in preparation for reaching those final districts.

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Mali – TT Prevalence: Adults ≥ 15 years

Figure 1

1996

Figure 2

2009

Figure 3

2020

20

Mali – TF Prevalence: Children 1-9 years

Figure 5

2009

Figure 6

2020 1996

Figure 4

Figure 4

2020

21

Mali – Activities Remaining in 2021 to Achieve Elimination

Figure 8 – Five districts remain to complete ratissage and/or surveys to demonstrate achievement of the TT elimination threshold; they include Douentza and Koro (Mopti), Tominian (Segou), Koutiala (Sikasso), and Tombouctou (Tombouctou).

Mali – Ratissage Results

Figure 7 – As of 2020, nine districts will use ratissage data to demonstrate fulfillment of elimination criteria for TT. Five districts remain to complete survey or ratissage activities to demonstrate achievement of TT elimination criteria; according to impact survey, Tombouctou has a TT prevalence less than 0.2% but requires surveillance survey to confirm.

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SAFE in Niger

Presented by Dr. Kadri Boubacar, Coordinator, Programme National de Santé Oculaire (PNSO),

Ministry of Health (MOH) – Niger

Background

The PNSO, formerly the Programme National de Lutte contre la Cecité (National Blindness Prevention Program – PNLC), was established in 1987; national surveys showed a prevalence of blindness of 2.2%, with 25% of the blindness due to trachoma. Regional baseline surveys conducted from 1997 to 1999 found that 44% of children ages 1 to 9 years had active trachoma, and 1.7% of women over 15 years of age had TT. In 1999, the PNSO formed the National Trachoma Task Force (NTTF) and began district-level prevalence surveys in 2001. In 2019, based on recent impact survey results and the required SAFE activities remaining, the Program revised the target for elimination from 2020 to 2025. Currently of the 62 health districts that are or were ever endemic, 20 districts (or select evaluation units within) remain above the 5% elimination threshold for TF.


Indicator Goal National Carter Center-Assisted

Target Achieved Target Achieved

# of persons operated 8,540 8,000 2,379 3,000 788

# of women operated 1,573 532

# of surgeons trained 45 15 16 0

Doses of Zithromax®

distributed during MDA 1,597,902 1,597,902 1,456,968 N/A N/A1

Doses of tetracycline distributed during MDA

100,000 100,000 100,000 100,000 100,0002

# of villages with health

education 600 550 600 550

# of household latrines built 20,000 13,396 10,000 13,396

Surgery (S)

Since 2002, 148,517 TT surgeries have been conducted in Niger, with the greatest surgical output observed in 2014. The Carter Center has supported a total of 82,939 TT surgeries since 2009, mainly in Diffa, Maradi, and Zinder regions. According to recent data, 35 of the 62 endemic health districts in Niger have achieved the TT threshold (<0.2% TT in individuals 15 years or above); this leaves 27 health districts, or select evaluation units within a district, still above the 0.2% threshold, requiring further outreach. In 2020, 2,376 people received TT surgery, representing 30% of the annual target of 8,000. The Carter Center planned to support 3,000 TT surgeries in 2020 and reached 788 surgeries; nationally, a total of 15 new TT surgeons were trained. At the end of 2020, considering the annual surgical outputs, the estimated surgical backlog in Niger was 6,161. In order to achieve the trachoma elimination goals and reach the remaining TT cases nationwide, the National Program plans to implement a series of ratissage, surgical camps, and survey strategies.


The National Program reported that 42 out of the 72 districts in Niger have achieved the elimination target of less than 5% TF in children 1-9 years. Meanwhile, 20 districts have a TF prevalence of above 5%. In 2020, 1,456,968 doses of Zithromax® were distributed along with 100,000 doses of TEO; The Carter Center

1 The Carter Center does not currently assist implementing MDA in Niger. 2 The Carter Center does assist in purchasing tetracycline for MDA but does not participate in distribution activities.

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supported the MDA efforts by providing the 100,000 TEO doses. In 2021, eight districts require MDA, ten districts will conduct TSS, and 14 districts will conduct TIS. Niger expects to achieve elimination of trachoma as a public health problem in 2025 when the final two surveillance surveys are conducted.


In 2020, health education activities were conducted in 550 villages across Niger, with Carter Center assistance, to support the efforts to prevent trachoma transmission in communities. The Carter Center also supported the PNSO to construct 13,396 latrines and enhance latrine construction efforts by training 300 masons.


In 2020, due to the COVID-19 global pandemic, all activities related to surgical outreach and surgeon training were suspended for eight months, and surveys were postponed until 2021; F&E activities slowed but did not stop completely. During this time, the National Program, alongside its partners, implemented a RAMA tool and developed SOP to mitigate the risk of COVID-19 transmission during programmatic activities. These tools will continue to be used to assess and reduce the risk for the foreseeable future as COVID-19 continues to impact Niger.

Operational Research

Two operational research protocols (PESS: Post-Elimination Surveillance Survey and ARRET: Azithromycin Reduction to Reach Elimination of Trachoma) have recently been approved to be conducted in Niger, and one study (AVENIR: Azithromycine Pour la Vie Des Enfants au Niger - Implémentation et Recherche) is currently being implemented.

Programmatic Successes and Challenges

The National Program is currently focused on organizing data to be used to complete the dossier, as it has been discussed that dossier development should begin early. The data organization activities include updating data, confirming data for newly created districts, and ensuring that each region shares data and information with its districts.

In addition to the challenges due to the COVID-19 pandemic, the program noted challenges with maintaining coverage of MDA above 80%. Additionally, the Program had hoped to make more progress in reducing the TT surgical backlog and increase surgical coverage overall in 2020. Still, due to the delays with COVID-19, that was not possible.


Surgery (S)

• Operate 5,000 TT cases, 3,000 with Carter Center assistance • Train 36 TT surgeons, 20 with Carter Center assistance


• Distribute 1,577,042 doses of Zithromax® in eight districts

• Distribute 100,000 doses of TEO; The Carter Center will provide all TEO


• Conduct health education in 550 villages, all with Carter Center assistance

• Construct 20,000 latrines, 10,000 with Carter Center assistance

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Surveys

• Conduct 14 TIS and ten TSS


• Begin implementation of PESS and ARRET • Continue implementation of AVENIR

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Niger – Activities 2021 MDA & Surveys

Figure 3 – In 2021, eight districts plan to conduct MDA, ten districts will conduct TSS, and 14 districts will conduct TIS.

Figure 1

Niger – 2020 TT Prevalence: Adults ≥ 15 years

Figure 2

Niger – 2020 TF Prevalence: Children 1-9 years

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SAFE in South Sudan

Presented by Mr. Makoy Samuel, Director for Guinea Worm Eradication Program (GWEP) and

Preventive Chemotherapy – Neglected Tropical Diseases (PC-NTDs), Ministry of Health (MOH), South Sudan

Background

Prevalence surveys conducted between 2001 and 2008 showed TF prevalence as high as 80% among children ages 1 to 9 years old and TT prevalence as high as 15.1% among adults 15 years and older in some counties. Over half the country has not received baseline surveys; therefore, the true magnitude of trachoma within South Sudan is unknown. In areas known to be trachoma endemic, SAFE activities have not been conducted in all the counties due to a lack of resources or inaccessibility. The first national trachoma action plan (TAP) was completed in 2012, and a regional TAP was conducted covering five counties in Eastern Equatoria state in 2019. In 2020, the second version of the National NTD Master Plan covering 2021-2030 was adopted. The Master Plan includes trachoma targets and programmatic strategies.


Indicator Goal National

Carter Center-

Assisted

Target Achieved Target Achieved

# of persons operated 8,300 1,200 122

(10%) 530

72

(14%)

# of women operated 98

(80%)

60

(83%)

# of surgeons trained/retrained 5 0 - -

Doses of Zithromax® distributed

during MDA 1,743,793 506,651

329,537

(65%) 303,030

329,537

(108%)

Doses of tetracycline distributed

during MDA 104,628 30,399

22,250

(73.1%) 16,043

22,250

(138.6%)

# of villages with health education 1,670 2,046

(122.5%) 1,000

2,046

(204.6%)

# of household latrines built 80 0 - -

Surgery (S)

Over 50,000 people across 29 counties require TT surgery. Since 2001, the National Program has provided a total of 21,769 TT surgeries across South Sudan.

Based on survey results in 2015 and surgical activities conducted between 2015 and 2020, 2,533 people still require TT surgeries across five counties of Eastern Equatoria state. A total of 122 surgeries were conducted in 2020, 72 of which were conducted with the assistance of The Carter Center. Of the surgeries undertaken, 83% were provided to women. Performing TT surgeries was made extremely difficult due to the COVID-19 pandemic. Surgeries were carried out in February 2020 and then suspended due to the global pandemic. While adapted protocols were developed, surgery was considered a high-risk activity in terms of COVID-19 transmission, especially considering the close physical contact between a surgeon and patient. A total of 6,000 TT surgeries have been targeted in 2021, 900 of which are targeted to be conducted with the support of The Carter Center.

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Of the annual MDA target for 2020, 351,787 people were reached with azithromycin or TEO across five counties in Eastern Equatoria state (Kapoeta East, Kapoeta North, Kapoeta South, Budi, and Lopa-Lafon). For the three Kapoeta counties mentioned, the fifth out of five rounds of MDA were conducted. It was the first of three rounds of MDA in Budi and the second of five rounds in Lopa-Lafon. The last MDA carried out in Lopa-Lafon dates back to 2016. In January 2021, Jie and Kessengor were both reached to complete the 2020 MDA cycle. Both Jie and Kessengor have been extremely hard to reach due to heavy rains, flooded swamps, and transport inaccessibility. Porters and donkeys carried drugs and food for over two days to reach their destination. In 2021, MDA will be conducted in Eastern Equatoria state, Jonglei state, and Unity state.

In 2021, 25 counties will be mapped across Unity, Jonglei, Upper Nile, and Central Equatoria states. In addition, Kapoeta East, Kapoeta North, and Kapoeta South counties in Eastern Equatoria state will have TIS. In 2021, based on known funding, 15 districts are targeted to conduct TIS, and 13 districts are targeted for baseline surveys.


The National Program provided health education activities in 2,046 villages in 2020, reaching 122.5% of its target for the year. Health education efforts, one of the F&E components of the SAFE strategy, are continuous throughout surgery and MDA campaigns. Drug distributors, TT case finders, supervisors, county authorities, and local chiefs are all trained to use the trachoma flipchart. During any distribution, an emphasis is placed on providing health education in schools. Increased integration of WASH partners for trachoma – and NTDs in general – health education is critical, as is increased collaboration between WASH and NTD partners.

Due to the COVID-19 pandemic and programmatic challenges regarding WASH integration, latrine construction targets were not met in 2020. The National Program recognizes that a concerted effort needs to be made to reinforce the E aspect of the SAFE strategy, including the renewed inclusion of WASH partners in NTD-Trachoma activities. The F&E components are the root of a sustainable path towards the elimination of trachoma as a public health in South Sudan.

COVID-19 Impact, Challenges, and Mitigation Measures

The COVID-19 pandemic deeply impacted the National Program. As advised by the WHO, NTD programs in South Sudan suspended most of their program activities due to community transmission risk; this included surgery campaigns, MDA, and surveys. Trachoma MDA and surgery activities were paused from March to September 2020; thus, surgery and MDA targets were not fully met. Also, the Program had to face unexpected budget impacts due to the required purchase of PPE.

From March to September 2020, the National Program focused on developing protocols and new SOP to prepare the country for the resumption of activities, once deemed safe. Due to COVID-19, a RAMA was conducted to effectively understand and mitigate transmission and exposure risks during MDA and surgery outreach. MDA work plans were reorganized and redesigned to allow for a pilot MDA activity to be conducted following the adoption of the COVID-19 precautionary measures. House to house MDA was piloted as the official program strategy in September 2020 to ensure social distancing measures. However, this is not conducive to the traditional Kapoeta village, where several homes are within an enclosed space and people are treated per village rather than per house. All MDA team members used PPE during activities and followed hygiene protocols, such as regular hand and equipment sanitizing, outdoor training, and social distancing.

Upon the continuation of MDA activities, COVID-19 and trachoma health education was conducted simultaneously. In April 2020, a new tool kit was developed, in collaboration with the Guinea Worm Eradication Program (GWEP), the Trachoma Control Program, and the MOH, to improve communication

28

materials and adapt health messages to integrate hygiene and other messages relevant to COVID-19 prevention. This new tool is now being used throughout all MDA activities.

Other challenges include: the need to complete baseline mapping in over half of the country, lack of donor and implementing partner support for known endemic regions, few TT surgeons, and low levels of WASH infrastructure. This lack of program support will continue to impede the Program’s attempts to achieve its elimination goals by 2030.


Surgery (S)

• Operate 6,000 TT patients, 900 with Carter Center assistance

• Train five TT surgeons


• Distribute 2,132,344 doses of Zithromax®, 400,000 doses with Carter Center assistance

• Distribute 127,940 doses of TEO, 24,000 doses with Carter Center assistance


• Conduct health education in 10,661 villages, 2,000 with Carter Center assistance • Construct 80 latrines

Surveys

• Conduct 15 TIS and 13 baseline surveys, three TIS with Carter Center assistance


• Proposed Study: F&E qualitative study among Toposa mothers • MDA feasibility study with a focus on the cost of interventions in South Sudan

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South Sudan – TT Prevalence: Adults ≥ 15 years

Figure 1

Baseline, 2001-2010 2020

Figure 2

30

South Sudan – TF Prevalence: Children 1-9 years

Figure 5

Baseline, 2001-2010

Figure 3

South Sudan – 2021 Planned MDA and Surveys

Figure 5

2020

Figure 4

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SAFE in Sudan

Presented by Dr. Balgesa Elshafie, National Coordinator, Trachoma Control Program, Federal Ministry of Health (FMOH), Sudan

Background

The elimination of blinding trachoma is one priority of the Federal Ministry of Health (FMOH), and government funds are allocated to support the Program. In 2012, the government allocated 1.5 million USD for five years to help support the Carter Center’s partnership for trachoma control. There is a strong coordination mechanism between the government, (represented by the FMOH and Federal Ministry of Finance) and The Carter Center.

National baseline prevalence mapping was conducted between 2006 and 2015. In Darfur, only 11 localities remain that still require baseline mapping. The FMOH conducts S, A, and F elements of the SAFE strategy. The E intervention is implemented by various federal and state ministries and is supported by UNICEF and other organizations. Since baseline surveys conducted in 2017 in South Sudanese refugee camps showed that full SAFE interventions are warranted, The Carter Center has supported the FMOH to conduct SAFE activities within the camps. In 2019, based on activities remaining in Sudan, the elimination target was revised from 2020 to 2025.


Indicator Goal National Carter Center-Assisted Target Achieved Target Achieved

# of persons operated 36,145 7,500 472 (6.3%) 2,100 229

(10.9%)

# of women operated 311 (65,8%) 167

(72.9%) # of surgeons trained/retrained 30 35

(116.6%) - -

Doses of Zithromax®

distributed during MDA 1,211,214 705,255 702,514 (99.6%) 505,959 394,643

(77.9%) Doses of tetracycline distributed during MDA 24,224 14,105 16,194

(114.8%) 10,119 5,544 (54.7%)

# of villages with health education 625 276 (44.2%) 252 176 (69.8 %)

Surgery (S)

The estimated surgical backlog in Sudan is now 36,055, over half of which is in the Darfur region, where no TT surgical services have been provided. Additionally, over 25% of this backlog is based on TT data collected during baseline surveys conducted 10-15 years ago in areas that TF results showed were not trachoma endemic. In 2020 the National Program provided 472 TT surgeries, reaching 6.3% of its annual target. The Carter Center assisted 229 of the total surgeries achieved, 10.9% of its annual target. The total number of women operated by the National Program was 311. The Carter Center supported 167 surgeries for women. To increase uptake of TT surgery, 35 TT surgeons were trained in 2020.

In 2020, 24,625 houses were reached through TT case finding activities in endemic villages. A total of 102 suspected TT patients were identified by case finders, 82 of which were confirmed as TT by the TT surgeons. From these, 36 cases received surgeries, and nine were referred to the hospital for treatment.

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TT case finding activities were also conducted in South Sudanese refugee camps. A total of 111 TT patients were confirmed to suffer from TT. From these cases, 95 cases were provided TT surgeries.


Through MDA in 2020, a total of 702,514 doses of azithromycin and 16,194 doses of TEO were distributed by the National Program. The Carter Center assisted the National Program in distributing 394,643 azithromycin doses and 5,544 TEO doses. MDA activities were also conducted in South Sudanese refugee camps. Due to the COVID-19 pandemic, MDA targets were not able to be met by the National Program.

In 2020, although 15 localities have achieved the TF elimination threshold, there are still 11 localities considered endemic, which is the equivalent to a population of 2,697,320 people. In 2021, a total of 11 localities are targeted for baseline surveys, eight localities are targeted for impact surveys, and 11 localities are targeted for surveillance surveys.


The National Program carried out F&E activities in 2020 during MDA and TT surgical camps. Due to COVID-19, precautionary measures were followed when conducting health education in 2020. Thousands of posters, pamphlets, and stickers were distributed. The Program also supported the broadcasting of radio messages and live television health programs using local language for announcements of activities conducted by mobile teams.

COVID-19 Impact, Challenges, and Mitigation Measures

Due to COVID-19, the implementation of several activities during 2020 were considerably delayed, including: two rounds of MDA, one impact survey, two surveillance surveys, and 11 baseline surveys. TT diagnoses, case finding interventions, and TT surgery trainings were also significantly delayed. Additionally, the COVID-19 pandemic caused delayed health education activities in school-level programs.

In order to mitigate the impact of COVID-19 in programmatic activities, the National Program worked on developing new SOP for fieldwork in the context of the disease. A RAMA tool was applied, and precautionary measures were adopted; wearing face shields, masks, using soaps and hand sanitizers, and social distancing were all taken into consideration when restarting programmatic activities.


In 2020, the National Program implemented a serological study monitoring Chlamydia trachomatis (Ct) antigens. This study is a sub-study within a trachoma baseline survey conducted in Kotom, El Seraif, and Seraf Omrah localities in North Darfur state. The study is in partnership with the CDC and The Carter Center. Survey teams measured trachoma clinical signs as part of baseline surveys and collected blood samples. All individuals over the age of one were targeted for clinical examination and blood sample collection. In 2020, dried blood spots (DBS) samples were sent to the CDC for further analysis.


In general, the implementation of activities in Sudan was negatively impacted by the COVID-19 pandemic as well as economic and political factors. Additionally, the shortage of TEO in local markets affected MDA activities. Lastly, the National Program continues to need donor support and funding to conduct TT surgeries in the Darfur regions as well as water provision and latrine construction in all trachoma endemic areas.

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Surgery (S)

• Operate 5,400 TT patients, 2,100 with Carter Center assistance • Train 30 TT surgeons


• Distribute 347,060 doses of azithromycin, 201,376 doses with Carter Center assistance • Distribute 6,941 doses of TEO, 4,110 doses with Carter Center assistance


• Conduct health education in 349 villages, 159 with Carter Center assistance

Surveys

• Conduct eight TIS, 11 TSS, and 11 baseline surveys

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Figure 3

Sudan – 2020 TF Prevalence: Children Ages 1-9 Sudan – 2020 TT Prevalence: Adults ≥ 15 years

Figure 1 Figure 2

Sudan – 2021 Planned MDA and Surveys

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Table 1. Summary of National Data from Trachoma Control Programs, Carter Center-Assisted Countries National Data as Reported for 2020 Ethiopia Mali Niger South Sudan Sudan Total Surgery

Surgeries N/R N/R 2,379 122 472 2,973 2020 Target N/R N/R 8,000 1,200 7,500 16,700

Percent Coverage N/R N/R 29.7% 10.2% 6.3% 17.8% Antibiotics Azithromycin

Doses N/R N/A 1,456,968 329,537 702,514 2,094,376 2020 Target N/R N/A 1,597,902 506,651 705,255 2,809,808

Percent Coverage N/R N/A 91.2% 65.0% 99.6% 74.5% Tetracycline Eye Ointment

Doses N/R N/A 100,000 22,250 16,194 132,900 2020 Target N/R N/A 100,000 30,399 14,105 144,504

Percent Coverage N/R N/A 100.0% 73.2% 114.8% 92.0% Facial Cleanliness and Health Education

Villages with Health Education N/R N/R 550 2,046 276 2,872 2020 Target N/R N/R 600 1,670 625 2,895

Percent Coverage N/R N/R 91.7% 122.5% 44.2% 99.2% Environmental Improvements

Latrines N/R N/R 13,396 N/A N/A 13,396 2020 Target N/R N/R 20,000 N/A N/A 20,000

Percent Coverage N/R N/R 67.0% N/A N/A 67.0% N/A=Not Applicable N/R=Not Reported Totals only include countries and districts where data are available.

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Table 2. National Trachoma Control Program Annual Targets 2021, Carter Center-Assisted Countries Targets†as Reported, March 2021

Ethiopia Mali Niger South Sudan Sudan Total**

Surgery Persons to operate for TT N/R N/A 5,000 6,000 5,400 16,400

Antibiotics Doses of azithromycin to distribute during MDA† N/R N/A 1,577,042 2,132,344 201,376 3,910,762 Doses of TEO to distribute during MDA N/R N/A 100,000 127,940 4,110 232,050

Facial cleanliness Villages to reach through health education N/R N/A 550 10,661 349 11,560

Environmental improvement Household latrines to construct N/R N/A 20,000 80 N/A 20,080

N/A=Not Applicable N/R=Not Reported §All targets are subject to change. †Antibiotic targets do not reflect ITI-approved allocations of Zithromax®

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Table 3. Carter Center-Assisted Implementation of SAFE, Carter Center-assisted output Summary of Interventions per Country, January - December 2020

Indicators Ethiopia- Amhara* Mali Niger

South Sudan Sudan Total

Surgery Persons operated for TT 7,132 N/R 788 72 229 8,221

2020 Target 33,872 N/R 3,000 530 2,100 39,502 Percentage 21.1% N/R 26.3% 13.6% 10.9% 20.8%

Antibiotics Doses of azithromycin distributed 0 N/A N/A 329,537 394,643 724,180

2020 Target 15,310,025 N/A N/A 303,030 505,959 15,786,982 Percentage 0% N/A N/A 108.7% 78.0% 4.6%

Facial cleanliness and health education Villages with ongoing health education 3,447 N/R 550 2,046 176 6,219

2020 Target 3,447 N/R 600 1,000 252 5,299 Percent Coverage 100% N/R 91.7% 204.6% 69.8% 117.4%

Environmental improvement Household latrines constructed N/R N/R 13,396 N/A N/A 13,396

2020 Target N/R N/R 10,000 N/A N/A 10,000 Percentage N/R N/R 134.0% N/A N/A 134.0%

*Amhara reports latrine ownership, not latrines constructed; data not included in Total N/A=Not Applicable N/R=Not Reported

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Table 4. Carter Center-Assisted Implementation of SAFE Cumulative Interventions per Country, 1999-2020

Indicators Ethiopia-Amhara Mali Niger

South Sudan Sudan Total

Persons operated for TT 715,259 30,914 84,856 10,787 12,196 854,067 Doses of azithromycin distributed (MDA) 182,748,584 698,083 3,780,392 3,991,679 8,138,879 199,357,617 Villages with ongoing health education 3,871 3,886 1,708 3,574 664 13,703 Household latrines constructed 3,336,513 116,722 165,070 646 N/A 3,618,951 N/A=Not Applicable

39

50,572

33,872

1,200

7,500

8,000

10,105

7,132

122

472

2,379

0 10,000 20,000 30,000 40,000 50,000 60,000

Total

Ethiopia-Amhara

South Sudan

Sudan

Niger

Figure 1. Persons Operated for TT, Carter Center-Assisted CountriesNational Program data as presented for January - December 2020

Persons Operated in 2020

Persons Targeted for Surgery in 2020

40

18,119,833

15,310,025

506,651

705,255

1,597,902

2,489,019

0

329,537

702,514

1,456,968

0 2,000,000 4,000,000 6,000,000 8,000,000 10,000,000 12,000,000 14,000,000 16,000,000 18,000,000 20,000,000

Total

Ethiopia-Amhara

South Sudan

Sudan

Niger

Figure 2. Azithromycin Distribution, Carter Center-Assisted CountriesNational Program data as presented for January - December 2020

Doses of Azithromycin Distributed in 2020

Doses of Azithromycin Targeted for Distribution in 2020

41

6,342

3,447

1,670

625

600

6,319

3,447

2,046

276

550

0 1,000 2,000 3,000 4,000 5,000 6,000 7,000

Total

Ethiopia-Amhara

South Sudan

Sudan

Niger

Figure 3. Health Education, Carter Center-Assisted CountriesNational Program data as presented for January - December 2020

Villages with Health Education in 2020

Villages Targeted for Health Education in 2020

42

Persistent and Recrudescent TF: Patterns and Programmatic Implications

Presented by Dr. Jeremiah Ngondi, Senior NTD Advisor, Act to End NTDs - East, RTI International

Background

Global elimination of trachoma as a public health problem was targeted for 2020; however, only ten countries

had been validated by the beginning of 2020. Despite not meeting the ambitious 2020 elimination goals, many

countries have made steady progress towards the attainment of elimination. As programs gear towards the new

2030 NTD roadmap targets, innovative approaches are needed to enhance the timely attainment of elimination

and to sustain the elimination gains post-validation. The WHO advocates for implementation of MDA with

azithromycin, where prevalence of TF in children aged 1-9 years is above 5%. The recommended annual MDA

is implemented in varying cycles depending on TF prevalence as follows: one annual round if TF=5-9.9%;

three annual rounds if TF=10-29.9%; five annual rounds if TF=30-49.9%; and seven annual rounds if

TF≥50%.

A number of end-game challenges that put country programs at risk of not attaining timely elimination of

trachoma have been identified, including districts not attaining TF<5% following multiple cycles of MDA and

TIS and districts not sustaining TF<5% during TSS. In most endemic countries, the majority of districts attain

and sustain TF<5% after one or two MDA cycles; however, some districts struggle to escape a repeating

“MDA-TIS-MDA-TIS-MDA” cycle, and some districts experience a rebound of TF (≥5%) at TSS and thus,

per current guidance, have to restart another MDA cycle. Because of these “vicious cycles,” there may be a

considerable time lag from when the first district in each country attains elimination of TF<5% to the time

when the last district in the same country attains the TF elimination target. As a result, country programs may

be caught up in a decade-long implementation of SAFE in just a few districts where TF remains above 5%;

and, if these problematic “cycles” remain unbroken, countries risk missing the 2030 goals as they did the 2020

goals.

Operational definitions

Based on recent discussions within the trachoma elimination community, the following operational definitions

are proposed for persistent TF and recrudescent TF.

Persistent TF can be defined as any district that has had two or more TIS, and TF prevalence has remained

above 5% and therefore will require further cycles of MDA. Based on the trends from the global atlas of

trachoma, persistent TF can further be sub-classified as “high persistent TF” where prevalence remains above

10% and “low persistent TF” where prevalence tracks within the 5-9.9% range.

On the other hand, recrudescent TF can be defined as any district where TF prevalence rebounds to 5% or

more at TSS. Based on the emerging trends from the global atlas of trachoma, recrudescent TF can be sub-

classified into “high recrudescent TF” where prevalence rebounds to >10% and “low recrudescent TF” when

the rebound prevalence ranges between 5-9.9%.

Programmatic implications

Persistent TF has programmatic implications in that multiple cycles of MDA will be needed in districts with

persistent TF. For low persistent TF, TIS will be needed between each annual round of MDA – anecdotally,

there are districts in certain countries that have had up to five annual MDA-TIS cycles before attaining the

elimination threshold of TF<5%. There is also evidence suggesting that districts with persistent TF are likely

to experience recrudescent TF during TSS, thus further propagating the vicious cycle. In some countries, only

a few districts have persistent TF, which implies that the trachoma elimination program must be continued in

those few districts.

43

Recrudescent TF on the other hand implies that districts have to restart MDA as per current guidelines.

Restarting MDA in districts where TF elimination thresholds had been achieved can be challenging because

enhanced social mobilization is needed to explain to recipient communities why further MDA is needed.

Districts with high recrudescent TF mean that at least three rounds of MDA will be needed, thus extending the

elimination timeline by at least five years. Low recrudescent TF means that elimination timelines will be

extended by at least three years. Finally, emerging data suggest that there is a small sub-set of districts that have

had two or more episodes of low recrudescent TF, which means that the elimination timelines could be

extended by at least six years in such settings.

Conclusion and recommendations

Persistent TF and recrudescent TF not only prolong timelines to the attainment of elimination but also causes

national programs to continue the implementation of MDA for a considerable period in just a handful of

districts. Evidence suggests that districts with persistent TF are likely to experience recrudescence TF at TSS.

This suggests that in districts with persistent TF, sufficient antibiotic pressure is needed to ensure timely

attainment of TF elimination threshold and sustaining of TF below elimination threshold at TSS. This can be

attained by longer MDA cycles before TIS by extending the number of annual MDA rounds or by undertaking

two or more annual rounds of MDA. For districts with recrudescent TF, extending the antibiotic pressure

beyond the current recommended rounds will provide the best chance to get the elimination targets back on

track and attain timely elimination. Two or more annual rounds may be an appropriate approach to ensure

timely attainment of elimination thresholds.

44

Persistent Trachoma: What have we learned? Lessons from Amhara, Ethiopia

Presented by Dr. Scott Nash, Epidemiologist, Trachoma Control Program, The Carter Center

The global trachoma control program has observed remarkable progress in reducing trachoma across the world

since the establishment of the SAFE strategy. Since going to scale with SAFE in the Amhara region of Ethiopia,

nearly 30% of the region (49/166 districts) has reached the TF threshold for elimination of trachoma as a public

health problem. Despite this progress, there remains a considerable number of districts experiencing

persistently hyperendemic levels of trachoma. The aim of this presentation was to describe the epidemiology

of persistent trachoma within Amhara using data from serial population-based surveys, randomized control

trials, and mathematical modeling.

Since 2011, the Trachoma Control Program in Amhara, Ethiopia, has been collecting alternative trachoma

indicators alongside clinical signs within annual programmatic population-based surveys. Data on Ct infection

and serological responses can better help characterize persistent trachoma. Recent data from trachoma surveys

have demonstrated that nearly 30 districts remain above the 30% TF cut point among children ages 1 to 9 years,

indicating hyperendemic trachoma despite approximately ten years of SAFE interventions. Further, in the

Waghemra zone, in the northeast of the region, the zonal prevalence of ocular Ct infection remained

considerable at 12% among children ages 1 to 5 years as of 2020. Although the zone observed a reduction from

2015 (18%), this high level of infection accompanied a district TF prevalence range well above the elimination

threshold (17% to 54%). In the neighboring South Gondar zone, DBS were collected to test for antibody levels

to trachoma antigens. In Andabet district, South Gondar, the seroprevalence of trachoma antibodies reached

as high as 58% by age seven years with the population-based sample, suggesting ongoing transmission. Further

south in the region, in Merebete district of the North Shoa zone, a TF prevalence of 36% was observed in a

2019 survey. Along with the hyperendemic TF, the district had a Ct prevalence of 34%, and a considerable

number of the Ct positive children had high-load infections. The data from these surveys demonstrate areas of

persistent TF within the Amhara region and objectively show considerable ongoing trachoma transmission

despite ten years of A, F, and E interventions.

Several cluster randomized control trials have been conducted to test alternative “A” strategies for trachoma

control within highly endemic districts in Amhara. In one long-running trial in Goncha district, East Gojjam

zone, communities were randomized to either annual or biannual MDA. The duration of the trial was seven

years, and MDA coverage was greater than 90% at each treatment round. By the end the trial, the average

infection prevalence in those arms with continual treatment (both annual and biannual treatment) was

approximately 6%, while the TF prevalence was still at hyperendemic levels (33%). In another trial conducted

in hyperendemic Waghemra zone, communities receiving two annual rounds of MDA with over 90% coverage

among children ages 1 to 5 years had increases in Ct infection by the end of the study, reaching an average

prevalence of approximately 16% (up from 8%). These data demonstrate that even under nearly ideal

conditions, it is hard to reduce Ct to very low levels and that TF is slow to respond to either annual or biannual

MDA pressure.

Lastly, recent mathematical models have been published to project trends in trachoma prevalence over the

longer term. These models demonstrated that within trachoma hyperendemic areas, current interventions will

not drive districts below the elimination threshold (5% TF) by 2030. The models also showed that only with

enhancements to the A component, such as extra rounds and targeting children, do hyperendemic areas reach

the elimination threshold by 2030.

Amhara has seen great reductions in trachoma since the start of the program. However, increased focus will be

needed in areas experiencing persistent trachoma. A strong commitment to the SAFE strategy coupled with

data-driven enhancements and adaptations are necessary to drive the elimination of trachoma as a public health

problem in Amhara and nationwide in Ethiopia.

45

Genomics Of Ocular Chlamydia Trachomatis After 5 Years Of SAFE Interventions for Trachoma in Amhara, Ethiopia

Presented by Dr. Harry Pickering, Department of Pathology and Laboratory Medicine, University of California, Los Angeles

To eliminate trachoma as a public health problem, the WHO recommends the SAFE strategy. As part of the

SAFE strategy in Amhara National Regional State, Ethiopia, the Trachoma Control Program distributed over

124 million doses of antibiotics between 2007 and 2015. Both administrative and self-reported coverage have

demonstrated treatment coverage in the region to be close to or above the WHO recommended minimum

threshold of 80%. During this time, the program also provided village-based and school-based health education

and assisted in the construction of latrines as part of the F and E components of SAFE. Despite these

interventions, trachoma remained hyperendemic in many districts, and a considerable level of Ct infection was

evident. Historically, Ct molecular epidemiology predominantly focused on ompA, the gene encoding the major

outer membrane protein. Since 2010, there has been a rapid expansion of Ct whole-genomic sequencing (WGS)

due to the ability to sequence directly from clinical samples. Despite more than 700 Ct genomes being publicly

available, few studies have evaluated the role of genome-level variation in Ct transmission and clinical outcomes

of Ct infection. Recent publications have begun to address these questions in Ct populations from trachoma-

endemic settings and have shown higher diversity than expected, compared with the sequencing of cultured

isolates. WGS additionally allows monitoring the emergence of antimicrobial resistance alleles in Ct, which is

of critical importance as MDA with azithromycin is key for trachoma control and is also under consideration

as an intervention for childhood mortality, neonatal sepsis, and bacterial skin diseases.

The Trachoma Control Program in Amhara has conducted multiple studies to better understand the

epidemiology of trachoma in communities that have received approximately five years of annual MDA with

azithromycin yet still have significant levels of Ct infection and trachomatous disease. The resolution of WGS

allows for a greater understanding of Ct transmission patterns, presence of putative virulence determinants, and

identification of antimicrobial resistance alleles. Therefore, this study, using samples collected from the Amhara

region, sequenced the first ocular Ct genomes from Ethiopia, a country with 44% of the global burden of

trachoma. We utilized residual material from Abbott m2000 Ct diagnostic tests to sequence 99 ocular Ct samples

from Amhara and investigated the role of Ct genomic variation in the continued transmission of Ct following

five years of SAFE.

We found sequences were typical of ocular Ct, at both the whole-genome level and in tropism-associated genes,

yet phylogenetically distinct from most previously sequenced Ct genomes. There was no evidence of macrolide-

resistance in this Ct population. Genome-wide analyses identified a polymorphic region around the ompA gene

associated with village-level prevalence of trachoma. Additionally, greater ompA diversity at the district-level

was associated with increased Ct infection prevalence.

Despite approximately five years of azithromycin MDA, we found no evidence for Ct genomic variation

contributing to the continued transmission of Ct after multiple rounds of treatment, adding to previous

evidence that azithromycin MDA does not drive acquisition of macrolide resistance alleles in Ct, supporting

continued treatment in communities where trachoma prevalence remains consistently high. This study

demonstrates feasibility of WGS of low-load, residual material and highlights the added value of collecting

ocular swabs as part of routine trachoma surveys. Collection and long-term storage of these samples has helped

alleviate concerns of azithromycin resistance to Amharan Ct, while offering important insights into the

relationship between ompA variation and Ct infection levels. Future longitudinal investigation will be needed

to understand what impact, if any, ompA diversity may have on treatment success in this setting.

46

South Sudan: A Face Washing Qualitative Study

Presented by Dr. Angelia M. Sanders, Associate Director, Trachoma Control Program, The Carter Center

Background

Trachoma among the Toposa

Within South Sudan, the Toposa are an ethnic minority group predominantly living in Eastern Equatoria state.

This area borders Kenya, Ethiopia, and Uganda and is known to be endemic for trachoma.3,4 Based on 2015

trachoma prevalence data, TF in children ages 1 to 9 years ranged from 30% to 48% across three counties

where the Toposa live, and TT ranged from 2.6% to 3.7% in those ages 15 years and above.5 Both the TF and

TT indicators show that these communities are significantly above the WHO thresholds for trachoma

elimination as a public health problem.

Social Marketing

Social marketing is a program planning tool that can be used to guide development and implementation of

behavior change interventions.6 Social marketing seeks to develop and integrate marketing concepts with other

approaches to influence behaviors that benefit individuals and communities for the greater social good. Key

elements of this approach include behavioral focus, audience segmentation, competition and exchange,

formative research, and application of theories of change. As part of a multi-year project, a social marketing

approach will be used to guide development and implementation of behavior change interventions targeting

how Toposa mothers in South Sudan keep their young children’s faces clean.

Planned Research

Overarching research question: Does a social marketing-based behavior change campaign lead to increased facial

cleanliness and decreased trachoma prevalence among Toposa children?

Formative research question: What motivators, drivers, barriers, and contextual factors impact Toposa mothers’

face washing behaviors of their young children?

Before the overarching question is answered, a social marketing-based behavior change campaign must be

developed based on an understanding of the target audience’s motivators, drivers, barriers, and contextual

factors. Formative research must be conducted among Toposa mothers to gather the necessary information;

since they are primarily responsible for the hygiene of their young children and, therefore, the target audience

for the behavior change campaign. Three forms of qualitative data collection will be used as part of formative

research: participant observation, journey mapping, and in-depth interviews (figure one, box one, and box two).

Participant observation will take place in locations that are believed to have relevance to the research question

and could provide insights into the target population’s physical, cultural, and social environment. It also allows

for observation of relationships, among and between people, and behaviors and activities people engage in, all

of which can directly or indirectly impact decision making. Journey mapping is a way of identifying key

3 Ngondi, J., Onsarigo, A., Adamu, L., Matende, I., Baba, S., Reacher, M., . . . Zingeser, J. (2005). The epidemiology of trachoma in Eastern Equatoria and Upper Nile States, southern Sudan. Bulletin of the World Health Organization, 83(12), 904-912. doi:/s0042-96862005001200012 4 Sanders, A. M., Stewart, A. E. P., Makoy, S., Chebet, J. J., Magok, P., Kuol, A., . . . Nash, S. D. (2017). Burden of trachoma in five counties of Eastern Equatoria state, South Sudan: Results from population-based surveys. PLoS Neglected Tropical Diseases (6), e0005658. doi:https://doi.org/10.1371/journal.pntd.0005658 5 Ibid. 6 Lee, N., & Kotler, P. (2011). Social marketing: influencing behaviors for good (4th ed.): SAGE Publications.

47

moments, also known as ‘touch points,’ and understanding the emotional impact of a behavior or experience.

The primary goal of journey mapping is to understand how these touch points assist or interfere with the

decision-making process. For example, what are moments in the day where a mother is most likely to make a

decision about face washing? In-depth interviews will be conducted with Toposa mothers and will focus on

their experiences, perspectives, feelings, and attitudes.

Once this formative research is complete, a social marketing behavior change campaign will be developed and

implemented among Toposa mothers. The program will be measured based on results from a baseline and

impact survey (figure one, box three, and box four).

Figure one: Phases of data collection and program implementation

Conclusion

This multi-year project will be innovative through its use of a social marketing framework to guide its various

phases (data collection and analysis, product design, and implementation). Based on research to date, a social

marketing approach has not been used among the Toposa of South Sudan, nor is there currently any peer-

reviewed documentation of a qualitative study being conducted among Toposa women regarding their WASH

practices. Lessons and insights learned in this study could be used for neighboring tribes from the same ethnic

group living in endemic areas of Uganda, Kenya, and Ethiopia. It is hoped that development of skills related to

conducting formative research within South Sudan can be used for other aspects of the SAFE strategy like TT

surgery uptake, participation in MDA, and the building and use of latrines.

PO PO JMJM

1 Documented observations and identification of touchpoints

Identification of questions to be included in IDI guide

3

Development of a behavior change campaign

2

Implementation of behavior change campaign

Abbreviations: PO = Participant observation; JM = Journey mapping; IDI = In-depth interview

Implementation of quantitative baseline survey

Implementation of IDI guide

4Implementation of quantitative impact survey

48

Health Campaign Effectiveness Coalition - Overview

Presented by Dr. Kristin Saarlas, Director, Health Campaign Effectiveness Coalition (HCEC), The Task Force for Global Health (TFGH)

The Health Campaign Effectiveness Coalition (HCEC) is a cross-campaign coalition that fosters learning and

systems change. The Coalition brings together country leaders, donors, multilateral organizations, and NGOs

from several large-scale health campaign domains, such as malaria, NTDs, immunization, polio, and Vitamin

A, as well as specialists in health systems, ethics, and health economics.

The program was launched in December 2019, with funding from the Bill & Melinda Gates Foundation to the

TFGH. A landscape analysis of the strengths, challenges, and opportunities within current health campaigns

informed the design of the program. Campaigns that were considered included MDA for NTDs such as

trachoma, onchocerciasis, lymphatic filariasis, deworming programs; polio and other immunization campaigns;

malaria bed net provision; and vitamin A supplementation. These programs have all been very successful, but

the analysis found that countries with multiple campaigns often had an overlap in timing and target populations

with limited communication and collaboration between campaign planners and partners. The resultant

operational inefficiencies have strained country health systems, burdened community health care workers, and

challenged our ability to meet country and global health goals. However, stakeholders identified multiple

opportunities to share campaign infrastructure, explore integrated approaches, and learn from each programs’

best practices. The final steps towards ambitious disease eradication and elimination targets require bold

strategies to reach the most difficult-to-reach populations, and policies that support country capacity and

ownership to sustain health gains.

The HCEC’s vision (https://campaigneffectiveness.org/our-vision-goals/) was developed through a

collaborative process by our leadership and coalition design team (including colleagues from The Carter Center

and TFGH’s trachoma programs). The vision and goal are as follows:

Vision: Country-led health systems use a strategic balance of targeted health campaigns in concert with

regular health services to achieve and sustain health-related development goals for all people.

Goal: Health systems objectives are met through highly effective and equitable use of campaigns that are

planned and delivered in conjunction with ongoing health services and that reach all populations targeted

for the intervention(s).

The HCEC’s vision, goals, and theory of change model informed three key roles for the coalition:

First is to foster improved communication and collaboration across campaign domains, countries,

implementers, multilateral organizations, and funders. The sharing of promising practices has been going on

for some time within our respective health domains--but there’s not one place to go to find resources and tools

that can work across campaigns. The HCEC can be that place that brings it all together to discuss, document,

and accelerate the learning.

Second is the need to build the evidence base. We see an important role for this Coalition in supporting

implementation research that will identify, test, and scale-up effective health campaign practices, approaches,

and tools.

Third is to use those findings to align global partners around any necessary programmatic and policy changes.

The Coalition fosters continuous learning and systems change, especially through global policy alignment

around campaign funding, incentives, and support. This includes the adoption of principles to guide efforts to

enhance cross-campaign coordination and the strengthening of health systems.

49

The 2021 priority activities were extensions of these three key roles. Improved communication and

collaboration were advanced through our first Coalition meeting in October 2020 and via subsequent “test and

learn” webinars that convened colleagues to share ideas, emerging research findings, and their application to

other country contexts. Moreover, our campaign integration working group is developing a decision guidance

toolkit for people-centered integration of health campaigns to have countries use and adapt to their needs.

Discussing, documenting, and accelerating learning, and building the evidence base was advanced through the

funding of eight case studies on collaborative campaign planning. Additionally, ten countries were recently

selected to receive implementation research awards on campaign integration and transitioning campaigns into

primary health care. Although findings are still emerging, there remains a need to look at where and how

countries can apply findings to develop new programmatic guidance.

The HCEC implementation research and learning agenda addresses key research and learning questions

organized according to three broad themes that involve restarting health campaigns during the COVID-19

pandemic, full and partial integration between health campaigns, and the interplay between campaigns and

primary healthcare systems. As reflected in the NTD Roadmap 2030 and other recent program guidance from

WHO; Gavi, the Vaccine Alliance; and the Global Polio Eradication Program, there is a renewed emphasis on

moving away from a silo approach to one that optimizes opportunities for collaboration between campaign

programs and, where it makes sense, integrating different interventions to build a more aligned approach within

health systems.

The opportunities for involvement and collaboration with the HCEC are many-fold between the Trachoma

Control Program and other NTDs that The Carter Center has been involved in for decades. First, there is the

opportunity to be engaged in implementation research on collaborative campaign planning and integration.

Building the evidence base involves contributions of promising practices as well as those that did not work.

Second, we encourage all to participate in sharing findings, practices, and lessons learned through our “test and

learn” series, other coalition events, website, and newsletter. Finally, new campaign practices of the Trachoma

Control Program can be shared back with Coalition members to broaden reach and improve global operational

efficiency.

For further information please access our website at http://campaigneffectiveness.org or contact

[email protected]

50

Literature Review Of Photography As An Imaging Tool For Trachoma

Presented by Dr. Fahd Naufal, Post-Doctoral Fellow, Wilmer Eye Institute, Johns Hopkins University

The WHO has targeted trachoma for elimination, defined with three criteria: first, the prevalence of TF in

children ages 1-9 years is sustained at <5% at district level; second, the prevalence of TT in persons age 15 and

older is <0.2%; and third, evidence that the health system can appropriately identify and manage TT. These

three criteria have been met when documented by two population-based surveys, spaced at least two years apart

and in the absence of MDA. As the prevalence of trachoma declines worldwide, performing field surveys to

validate elimination has become increasingly difficult, and field graders can lose familiarity with the clinical

findings of the disease. The challenges posed by training and standardizing highly skilled field graders may be

mitigated by using photography to augment or replace field grading.

In addition to minimizing the logistical issues of training skilled field graders, imaging may contribute to the

reduction of certain biases. Field graders may have preconceived ideas on the prevalence of trachoma in a

village or household, which can influence grading. Using images can mask graders to the trachoma status.

Images may also serve as a permanent record of trachoma status at the time of exam, which can be used for

validating field data and improve auditability. Furthermore, consensus on difficult cases using multiple graders

is more feasible when using images.

However, the use of imaging as a tool to detect trachoma requires further study as one or two images may not

be adequate to capture all the necessary information to accurately assess trachoma, particularly TT. Moreover,

quality assurance and quality control would prove difficult in the absence of standardized photographic tools

for trachoma. In conducting this literature review, our primary goals were to identify and summarize the

literature on the use of photography for trachoma detection. In particular, we sought to identify studies that

compare the concordance of field grades of trachoma with image grades, the concordance between field

graders, and between image graders. We also reviewed studies comparing various camera systems for capturing

images of TF, TI, as well as TT and eyelid contour abnormalities resulting from this disease. The concordance,

or agreement, is reported as the kappa statistic, which is a measure of the strength of association between

graders. The kappa statistic ranges from zero to one with one being perfect agreement. In research, agreement

of 0.7 or greater between graders is generally considered adequate.

We performed literature searches on the PubMed, SCOPUS, and Cochrane databases to identify papers

published between 1990 and 2020. The searches were conducted using a combination of the following

keywords: “trachoma”, “photograph”, “image”, “grade” and “prevalence”. Screening of abstracts, full-text

review and data abstraction were conducted by two reviewers. We included full-text, peer-reviewed articles that

used photography to either estimate the prevalence of trachoma, or to serve as a quality assurance mechanism

to compare with field grades; and described agreement between image graders, field graders, and/or image and

field graders. Articles where photography was not used or the agreements as described above were not reported,

articles using photographs solely to grade trachomatous scarring, or articles only reporting validation scores for

training graders were excluded.

We included 21 articles following the literature search after reviewing the abstracts of 265 titles. Nineteen

studies described the use of TF and trachomatous inflammation-intense (TI), one study described the grading

of images of eyelid contour abnormalities, and one study discussed the grading of TT using 2-D and 3-D

images. The type of camera system used was described in 14 studies. Single-lens reflex (SLR) cameras were used

as photography tools in 12 articles, whereas smartphone cameras were used in three, either as the sole

photography tool or in conjunction with SLR cameras. The reported number of ungradable images ranged

between 0.5% and 78%, as reported in six studies.

51

Our summary of kappa statistics (medians and ranges) is presented in Table 1 categorized as agreement between

Field vs Photo grades, Photo vs Photo grades, and Field vs Field grades for TF and TI. As a reference, Tropical

Data specifies an inter-grader kappa score of 0.7 or higher to assess a field grader’s ability to identify TF, which

may also explain the higher median kappa in the field vs field category. There are no formal assessment

requirements in terms of an agreement threshold for TI or TT. Agreement statistics for the presence of active

trachoma (TF and/or TI) that were not disaggregated were reported for two articles and not included in Table

1.

Table 1. Median and range of reported kappa statistics for TF and TI Active Trachoma –

Range of kappas and medians

Field vs Photo

(N = 10)

Photo vs Photo

(N = 8)

Field vs Field

(N = 2)

TF TF 0.57- 0.92 Median: 0.71

TF 0.37-0.90 Median: 0.68

TF 0.73 – 1.0 Median 0.86

TI TI 0.37-0.80 Median: 0.60

TI 0.47-0.83 Median: 0.71

TI 0.73 – 0.91 Median: 0.82

Though the kappa scores do not support the use of 3D images in the field for grading TT, training graders

using 3D images who then graded in the field showed matching performance compared to experienced graders

grading in the field. Therefore, using 3D images can be useful to train graders to detect TT.

Our overall findings suggests that there is potential in using photography to detect trachoma both as a research

tool and a training tool. This platform has good validity and reliability, depending on the quality of photographs

as well as the training level of graders. The agreement scores between field and photo grades were variable

among the papers, as there is potential for errors to be made during both types of grading. Agreement between

image graders were also variable but was greater when image quality and ungradable images were accounted

for. Grading by consensus using multiple image graders to determine the final image grades greatly improved

agreement between photographs and field grades. However, having more borderline cases can negatively affect

agreement, like in instances following antibiotic treatment when trachoma follicles tend to be smaller and more

difficult to grade. The type of gold standard used for comparison may also affect agreement; using field images

as the gold standard when testing validity is most common but that assumes that all patients were diagnosed

correctly.

Training and certification of image graders is necessary, and the photo sets used in training must include a full

spectrum of disease, including borderline cases, to adequately represent the variations seen in the field. Future

studies should aim to report the specifications of the imaging devices used as well as the number of ungradable

images that were present to aid in standardizing photography tools. Increasing field tests and training of

photographers in the field is needed to improve image quality. SLR images were slightly better than smartphone

pictures, but using newer smartphones and lens attachments can close the gap. Improvements in algorithms

and deep learning methods may provide a valid and convenient method of grading. Training photographers

may be less expensive than training and sending graders into the field; using regional grading centers for images

may be convenient and could reduce the need to send trained graders out into the field.

52

Photographic Grading For Trachoma Diagnosis Within Trachoma Impact Surveys: A Study In Amhara Region, Ethiopia

Presented by Ms. Cassidy Whitson, Health Communications Specialist, Centers for Disease Control and Prevention (CDC)

Photography is increasingly being used to capture the signs of trachoma for randomized trials, including those

conducted in the Amhara region of Ethiopia. In Amhara, conjunctival photographs have not yet been used as

a tool for monitoring and evaluation or quality control. As countries reach trachoma elimination as a public

health problem targets, finding community cases for field grader training may become difficult. We hope that

photographic grading will be able to be used as a tool for training and be integrated into existing control

programs.

To help answer some of these questions, The Carter Center embedded a photography pilot study within the

2017 TIS in Eastern Amhara. The aims of the study were to (1) assess the feasibility of including photographers

within survey teams, (2) assess the effectiveness of an in-country grading center, and (3) evaluate the

comparability of field and photographic grading in the Amhara region of Ethiopia. The photographer

accompanied four field graders to ten districts in Eastern Amhara. There was one cluster in each district and

field grader visited between two to three clusters each. The same photographer was embedded within each field

team. A total of 1,243 individuals of all ages were photographed directly following field grading. Both right and

left eye photographs were taken. A minimum of two photos of each eye were taken, and if photos were deemed

poor quality, more were taken.

As part of this study, The Carter Center partnered with the University of Gondar in Gondar, Ethiopia, to create

a new Gondar Grading Center. This center was created to grade study photos and build capacity of local

researchers in the Amhara region. The photo graders at Gondar Grading Center were ophthalmology students

or residents with background knowledge of trachoma. They were trained during a one-day training at Gondar

Grading Center which consisted of lectures and exercises and concluded with photo grading certification exam

conducted by University of California San Francisco ophthalmologist. To be certified, the trainees needed

kappa of 0.6 relative to the gold standard grade (consensus of a panel of three expert graders). All grader trainees

passed the exam and went on to grade study photos.

To grade the study photos taken by the photographer, two grading stations were set up at the grading center in

late 2019. The full photo set loaded onto each station. Two graders were assigned to station #1, and three

graders were assigned to station #2. The graders were able to come, log in, and grade when they were available,

which allowed for quick turnaround. Graders viewed two images of the same eye at the same time, were masked

to the field grade, and made determinations for TF, TI and TS. If both graders agreed, that became the final

grade for the photo. If they disagreed, the photo went to a third adjudication grader. This grader then made a

determination, which went on to be the final grade.

When comparing the field grades to the final photo grade, the kappa for TF was 0.701 and percent agreement

was 96.7%; for TI k=0.319, percent agreement was 94.7%; and for TS k=-0.086, percent agreement was 75.6%.

Agreement between field and final photo grades for TF was comparable to other results from controlled trials

assessing photographic grading for trachoma. However, the kappa for TS was less than zero, which suggests

that the grading center and field grade agreement performed worse than would be expected from chance alone.

This study demonstrated that gradable photographs can be taken under standard survey conditions and that

photographs can be graded quickly and efficiently at an in-country grading center. However, work is needed to

improve agreement between field and photo grades. As endemic countries progress forward towards

elimination targets and community cases of active trachoma decrease, validation of new cases with photo

graders may prove useful as a means of quality control.

53

International Coalition For Trachoma Control (ICTC) Updates

Presented by Mr. Scott McPherson, Senior Program Manager, RTI International, and Immediate Past Chair, International Coalition for Trachoma Control (ICTC)

About ICTC:

The ICTC is a multi-stakeholder coalition of over 50 non-governmental, donor, private sector, and academic

organizations working together to support the WHO Alliance for the Global Elimination of Trachoma by 2020

(GET2020 Alliance). Since our creation in 2004, ICTC has served as a forum for collaboration, shared learning,

and joint programming to support global efforts to eliminate trachoma as a public health problem and

advocated for and supported the implementation of the WHO-endorsed SAFE strategy.

Opportunities for the coming decade:

• The past year has been a year of unexpected challenges and disruptions brought about by the ongoing

COVID-19 pandemic. ICTC wishes to acknowledge WHO’s continued leadership to guide health

ministries and all stakeholders in supporting a comprehensive approach to combatting both COVID-19

and supporting the resumption of NTD activities where possible.

• ICTC also wishes to thank all health ministries, implementing partners, donors, industry, research, and

academia for their commitment to partnership and collaboration to work together during these challenging

times.

What the new WHO Global NTD road map means to ICTC:

• While we may not have reached our original 2020 goal of global elimination of trachoma as a public health

problem, the new road map assesses the challenges and barriers and sets out an updated course of action.

ICTC remains committed to supporting the WHO Alliance for the Global Elimination of Trachoma.

• The trachoma community has long demonstrated what can be achieved when cross-sectoral partnerships

are formed towards defined goals, evidenced by a 91% reduction in the number of people at risk of

trachoma since 2002 and ten countries being validated for eliminating trachoma as a public health problem

across WHO-endemic regions. Collaboration between health, WASH, education, and so many other

sectors is crucial to sustaining progress and advancing our contribution to strengthen health systems and

achieve new road map targets.

• ICTC is committed to delivering the new road map and supporting the paradigm shifts that underpin this

new road map through increased accountability, community empowerment and country led decision

making, and cross-sector collaborations to achieve our shared vision.

New ICTC Executive Group:

• This month, ICTC sees in new member elected leadership at the helm of ICTC for 2021 – 2023: Angelia

Sanders, Associate Director, Trachoma Control Program, The Carter Center is the new ICTC Chair; PJ

Hooper, Deputy Director, ITI is Vice Chair, and Scott McPherson, Senior Program Manager, RTI

International now serves as Immediate Past Chair.

• This Executive Group will be leading ICTC through a new phase of strategic engagement across ICTC

encompassing two new areas of work (i) an updated costings analysis of the delivery of the SAFE strategy,

which will in turn inform (ii) a new ICTC strategic plan for 2021 – 2030 in alignment with the new WHO

road map.

54

Updated costings analysis for the delivery of the SAFE strategy:

• In 2011, ICTC published the 2020INSight report, providing a snapshot of the global trachoma program at

the time, our vision for 2020 elimination, and a route on how to achieve our vision. This was the global

trachoma community’s first attempt to estimate the cost of delivering the full SAFE strategy.

• Based on the best available data at the time, these cost estimates helped the trachoma community to

approach donors, make an investment case for funding trachoma mapping and the scale up of the SAFE

strategy, mobilizing millions of US dollars in new financing. As we look towards the new iteration of the

strategic plan, we have a wealth of new information to draw upon to help us form updated and informed

estimates.

• Another informative tool that has supported advocacy for global trachoma elimination was the GET2020

Alliance's 2016 plan of action Eliminating Trachoma: Accelerating Towards 2020, which outlined what

needed to be done to scale up programs and strengthen health systems to achieve global elimination of

trachoma as a public health problem by 2020.

• In 2020, ICTC established a new Strategic Task Team composed of ICTC members and observers tasked

with creating a new resource and tool for the trachoma community to update costings for trachoma

interventions implementation, to inform a new strategic plan for the coming decade in alignment with the

new road map to 2030.

Parameters under consideration for updated costings analysis:

The goal is to create updated estimates

using broad strokes that help to articulate

advocacy messages and investment gaps

to support the global trachoma program,

based on updated identified gaps that will

play a role in the elimination of trachoma.

Already, through a series of interviews

with health ministry officials in 2020 and

ICTC meetings earlier this month, we

have started to gather feedback on how

the updated costings analysis can be

utilized to best frame future support for

regional plans, insecure settings, hard to reach populations (including indigenous and nomadic people), refugees

and internally displaced populations, as well as to better articulate how investments in trachoma elimination

can support overall health systems strengthening and capacity building.

Process to develop costings analysis and new strategic plan:

The process will include member and observer consultation, working through the ICTC strategic task team to

complete the costings exercise, with input from national trachoma program managers; peer review article

authored by national program managers; development of an ICTC document that serves as a tool for advocacy,

influencing and resource mobilisation for the global trachoma program over the coming decade.

Reviewing ICTC’s strategic direction and objectives:

1. Mobilise advocacy to increase political will for, and commitment to, trachoma elimination among

donors and decision makers.

55

2. Increase investment, as required in trachoma elimination programs and for the scale up of SAFE

interventions.

3. Strengthen capacity and human resources needed to achieve trachoma elimination by 2020.

4. Coordinate the provision of technical assistance and the sharing of knowledge to support high

quality outcomes in trachoma elimination programs.

5. Ensure an effective coalition model and way of working that responds appropriately to changing

contexts.

We will assess whether these priorities remain and whether nuanced changes in our operating context post

COVID-19 might identify additional gaps and priorities.

Reflections on the last 5 years of ICTC’s strategic plan:

• Advanced advocacy efforts to inform a range of policy and political discussions across the UK, US, and

Germany through national NTD coalitions, supporting advocacy efforts to build political will in donor

governments and to ensure data and evidence from the global trachoma program communicate the value

of investment in trachoma, the SAFE strategy, and NTDs. This is alongside efforts that ICTC members

have played with national partners in joint advocacy efforts at a national level in endemic countries.

• ICTC worked alongside a core group of stakeholders, including The Fred Hollows Foundation, Sightsavers,

Clearly, Peek Vision, IAPB, and OneSight, through the Vision of the Commonwealth campaign first

created by the Queen Elizabeth Diamond Jubilee Trust and now chaired by IAPB, in bringing trachoma

and vision to the agenda of the 2018 Commonwealth Heads of Government summit. This resulted in new

financing from the Commonwealth Fund to support trachoma elimination in selected Commonwealth

countries across Africa, Asia, and the Pacific 2018 -2020. The campaign is currently working to carry this

momentum on trachoma and vision to the June 2021 Commonwealth Heads of Government Meeting,

chaired by the Government of Rwanda.

• ICTC also works with other NTD networks, like the NTD NGO Network (NNN) and Uniting to Combat

NTDs, to ensure the global trachoma community has a seat and a voice on wider NTD platforms, to share

knowledge, experiences, and preferred practices that support cross-sectoral collaboration with the WASH

sector, data and surveillance, and communications efforts that can effectively share the successes,

challenges, and solutions from the trachoma community.

• With financial support from ITI, ICTC supports capacity building and technical assistance through the

submission of practical and policy-oriented articles that creates knowledge exchange through quarterly

issues of the Community Eye Health Journal to a broader eye health community.

• Since 2012, ICTC has produced 18 preferred practices across the SAFE strategy, including transition

planning toolkits, with translations available in French and some in Spanish and Portuguese, thanks to the

support of ICTC members and observers.

• As we reflect on our recent collective achievements together, ICTC would like to thank Sightsavers and

ITI for their ongoing support for ICTC’s operation and support to the secretariat; and thanks to all ICTC

members and observers for their contribution to ICTC’s shared work and achievements.

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Challenges for trachoma, NTDs, and eye health:

• Learning from experiences- COVID-19 has illustrated the degree of innovation and adaptability health

programmes around the world are mobilising; the trachoma community must learn from others, including

the eye health community, in order to maximise our next steps forward.

• Multi-sectoral engagement- this incudes WASH, disability inclusion, education, and nutrition sectors –

and the marriage of hard science and advocacy, from the very outset.

• Reframing the narrative for the ‘final mile’- as we move towards elimination as a public health problem

- extending the health and development narrative beyond our own specific disease focus to consider

common issues of sustainability, ongoing surveillance mechanisms, and effective health system

strengthening.

• Developing, engaging, and empowering a new generation of leaders in the NTD community- how

we identify and support stakeholders across research, programs, and spaces.

• Bringing hard science and research together into evidence-based influencing- we must ensure it is

being taken up and informing action and policy.

• Ensuring the leave no one behind- agenda includes a focus on poverty alleviation, equity and inclusion,

cross border issues, and insecure states.

• Surveillance- there is a risk of losing momentum and support when elimination targets are reached despite

ongoing support needed for surveillance and control efforts.

• Health systems strengthening- in order to succeed in achieving elimination targets, the NTD response

must support health systems and future-proof gains made against NTDs. Achieving elimination of NTDs

cannot be done without scale-up of efforts being underpinned by strong health systems. Sustaining

elimination requires addressing systemic challenges, such as governance, financing, health access, health,

and equity.

• Coalition building- ICTC acts in a manner of 'proactive responsiveness' to the felt needs of the GET2020

Alliance. We will continue to refine our mode of collaboration to achieve our objectives in a manner that

is agile, provides opportunities for members to engage, and is in close alignment with key GET2020

Alliance stakeholders. We know partnership and coalition building is hard; it requires trust, strong working

relationships, and transparency in information sharing and work planning to establish a coalition that

continues to function as an effective platform of collaboration. We are excited for the future ahead of us,

with continued shared vision, courage, and evidence and data driven strategies, we can achieve the global

elimination of trachoma as public health problem.

57

Compassion And Interconnectedness In Public Health

Presented by Dr. David Addiss, Director, Focus Area for Compassion and Ethics, The Task Force for Global Health (TFGH)

The term ‘compassion’ is used frequently in clinical medicine. A recent survey of hospital websites in the United

States revealed that almost 50% advertise their ‘compassionate care’7. In contrast, the word ‘compassion’ is

infrequently heard in public health settings. Yet, at a 2010 meeting on compassion and global health at The

Carter Center, participants concluded that “global health is rooted in the value of compassion and in an

awareness of our interconnectedness”8.

In many religious and spiritual traditions, compassion is regarded as arising from a deep awareness of how

interconnected we are with each other and with all beings. Karen Armstrong, a religious scholar, argues that,

arising from this awareness, the principle of compassion lies at the heart of all religious, ethical, and spiritual

traditions – it’s part of what makes us human9.

But what is compassion – and how does it relate to public health? According to social psychology, compassion

has three main elements: awareness of suffering; empathy, or emotional resonance; and action.

The infrequent use of the word ‘compassion’ in public health is likely related to several key challenges. First,

public health deals with populations, often at great geographic, cultural, and economic distances. When one’s

work is guided by statistics or abstract ideas rather than by encounters with individual human beings, one’s

awareness of the human dimension of suffering may not be sufficient to generate empathy. Sometimes, empathy

– putting ourselves in someone else’s shoes – must be an intentional choice. At the 2010 meeting mentioned

above, President Carter spoke about the intentionality of empathy. “When I became Commander in Chief, I

had to make certain that we didn’t reach a point where President Brezhnev felt the necessity of attacking my

country. So, I would sit early in the morning in the Oval Office. I had a big globe there and I would turn the

globe to Moscow and I would try to put myself in the position of Brezhnev.”

A second challenge to compassion is that public health operates through complex bureaucracies and

partnerships, which often shift the focus away from suffering individuals. And third, those bureaucracies and

the governments that authorize public health action may, at times, have values that are in conflict with those of

public health.

Responses to human suffering can be considered on a spectrum from cruelty at one extreme to mature

compassion, informed by wisdom, at the other. Cruelty may be considered a ‘far enemy’ of compassion. But

there are also ‘near enemies’ of compassion, such as pity. Mature compassion is rooted in solidarity, respect,

and a profound awareness of interconnectedness, while pity is often an expression of superiority. The French

philosopher and critic, Didier Fassin, is referring to pity when he says, “Compassion … always presupposes a

relation of inequality… When compassion is exercised in the public space, it is always directed from above to

below, from the more powerful to the more vulnerable”10.

How can we in public health overcome these challenges to compassion in our work? Recent developments in

compassion science suggest that we, as individuals, can improve our response to suffering through compassion

training. Compassion is a skill that we can develop. But public health operates through organizations and

7Kienast Y. Prolegomenon of an (spatial) Epidemiology of Compassion: A first look at the potentiality of mapping compassion from a bioethical & epidemiological perspective. Thesis, Master of Arts in Bioethics, James T. Laney School of Graduate Studies of Emory University, 2020 8 Conclusion of a Meeting on Compassion in Global Health, The Carter Center, Atlanta, September 2010. http://ccagh.org/resources/compassion-documentary/ 9 Charter for Compassion. https://charterforcompassion.org/charter/affirm 10 Didier Fassin. Humanitarian Reason. Berkeley: University of California Press, 2012

58

systems. It is more difficult – although entirely possible – to create and sustain compassionate organizations.

Compassionate leadership is essential, and increasingly, training in compassionate leadership is available,

including for global health leaders11.

Compassion appears to be gaining currency in public health. The WHO regards compassion as essential for

quality health services. Dr. Tedros Adhanom Ghebreyesus, WHO Director-General, recently said, “Quality is

not a given. It takes vision, planning, investment, compassion, meticulous execution, and rigorous monitoring,

from the national level to the smallest, remotest clinic”12. In another example, the FMOH in Ethiopia recently

identified compassion as a central pillar of its health sector transformation plan13.

Slowly, the ‘conspiracy of silence’ around compassion in public health appears to be lifting. The key to nurturing

compassion in public health was beautifully captured by Dr. Bill Foege when he addressed colleagues at CDC

almost 40 years ago. He said, “If we are to maintain the reputation this institution now enjoys, it will be because

in everything we do, behind everything we say, as the basis for every program decision we make—we will be

willing to see faces”14. Not modern laboratories, more robust epidemiologic methods, or increased funding –

as important as these are – but rather, the willingness to see, and be present to, the faces of suffering.

I’d like to express my gratitude to The Carter Center for being a such beacon of compassion in the world and

to the Trachoma Control Program for so beautifully exemplifying compassionate action.

11 Center for Compassionate Leadership. https://www.centerforcompassionateleadership.org/compassionate-leadership-and-resilience-training 12 Ghebreyesus, TA. How could health care be anything other than high quality? The Lancet 2018; 6(11): e1140-e1141. 13 Federal Democratic Republic of Ethiopia Ministry of Health, Health Sector Transformation Plan, October 2015, https://www.globalfinancingfacility.org/sites/gff_new/files/Ethiopia-health-system-transformationplan. 14 Bill Foege, Smallpox, Gandhi, and CDC – Fifth Annual Joseph Mountin Lecture, Atlanta, October 26, 1984.

Appendix I

59

2021 Trachoma Control Program Review Recommendations

General Recommendations:

1. National Programs should coordinate with ITI for any special needs related to MDA, including

securing catch-up treatments and special uses of Zithromax®.

2. Operational research should be conducted to see if more-frequent-than-annual MDA can control

trachoma in persistent districts. Infection data should be used in the assessment to build the evidence

base. Different strategies may be needed in different contexts.

3. Where relevant, donors and implementing partners should facilitate National Program coordination of

MDA, TT surgery, and health education activities across international borders (e.g. Niger and Nigeria;

South Sudan, Sudan, and Ethiopia).

4. National Programs should prioritize securing domestic financing towards programming, especially

WASH planning and implementation, and post-elimination activities (incident TT case management

and surveillance).

5. National Programs should prioritize collaborating and coordinating with relevant ministries to ensure trachoma prevalence and WASH coverage data are utilized as data driven approaches to WASH planning and implementation.

6. Operational research on WASH should be conducted to determine if different strategies are required

towards trachoma control, especially in trachoma persistent hyperendemic districts.

Country-Specific Recommendations:

Ethiopia

1. The National Trachoma Program should strengthen TT case finding through both house-to-house and

social mobilization strategies, with a special focus on districts with highest TT backlogs and hard to

reach areas.

2. The National Trachoma Program should look at additional ways to maintain the number of IECWs

across the country and reduce turnover.

3. The National Trachoma Program should consider alternative MDA strategies, specifically for

“persistent” hyper-endemic districts and those districts returning above 5% at TSS (in place of the

standard re-enrollment and re-survey approach).

4. The National Trachoma Program should ensure WASH implementation is prioritized to those districts

with the highest and persistent TF prevalence – and ensure the provision of water is accompanied with

behavior change communication interventions, sustainable maintenance, and monitoring and

evaluation plans conducive to trachoma indicators.

Amhara Regional State, Ethiopia

1. The Amhara Regional Trachoma Program should prioritize TT case finding efforts in districts with the

highest TT backlogs and hard to reach areas.

2. The Amhara Regional Trachoma Program should more widely implement systematic TT case finding

during house-to-house MDA strategies.

Appendix I

60

3. The Amhara Regional Trachoma Program should consider alternative strategies to represent the

remaining TT backlog, including using active TT case finding data rather than surveys, to demonstrate

progress.

4. The Amhara Regional Trachoma Program and other regional entities should ensure all WASH activities

and implementation are prioritized to those districts with the highest and persistent TF prevalence –

and ensure the provision of water is accompanied with behavior change communication interventions,

sustainable maintenance, and monitoring and evaluation plans conducive to trachoma indicators.

Mali

1. The National Program should establish a surveillance plan.

2. The National Program should ensure transition planning, including training of all relevant personnel,

is conducted before the end of 2021.

Niger

1. The National Program should begin work as soon as possible on transition planning and dossier

development.

2. The National Program should establish a surveillance plan.

South Sudan

1. The National Program should continue its work to secure sustained support for Unity state and other

endemic districts beyond 2021. The Program should collaborate with ICTC to identify potential

partners for collaboration.

Sudan

1. The National Program should focus efforts on confirming the accuracy of the current TT backlog

estimate – this may include collaborating with researchers to reassess locality-level TT prevalence

estimates.

2. The National Program should continue to work towards collaboration with the Academy of Health

Sciences to increase TT surgery uptake.

3. The National Program should search for funding, through various donors and partners, to provide

financial support specifically towards TT surgeries in the Darfur region.

Appendix II

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Trachoma: The Disease

Trachoma, the world’s leading cause of infectious blindness, is caused by repeated infections of the conjunctiva

(the lining of the eye and eyelid) by the bacterium Ct. As of July 2020, the WHO estimates that 1.9 million

people, the majority of whom are women, are blind due to trachoma, and another 137 million people are at risk

of blindness or severe visual impairment due to trachoma in 45 countries15. The early stage of the disease is

called inflammatory trachoma and is most common among children. Inflammatory trachoma can present as either

the formation of whitish follicles, on the conjunctiva under the upper lid or around the cornea, or as an intense

painful or uncomfortable inflammation with thickening of the conjunctiva. Women are repeatedly exposed to

inflammatory trachoma in their role as primary caretakers of children. It is therefore not surprising to find that

women develop chronic trachoma twice as often as men.Trachoma is transmitted through discharge from the

eyes and nose of infected individuals: (i) by contact with hands, towels, and clothing or (ii) by flies, which are

attracted to ocular and nasal discharge. As individuals are repeatedly infected with Ct, subsequent scarring of

the conjunctiva deforms the eyelid margin, resulting in eyelashes turning inward and rubbing against the cornea.

This condition, called trichiasis, causes disabling pain, physically abrades the cornea, and can lead to corneal

opacity and blindess if not corrected.

In 1987, eye care experts and the WHO developed a simplified trachoma grading scale, which facilitated and

standardized the diagnosis and identification of all stages of trachoma. In 1997, the WHO established the

GET2020 Alliance, which brought international non-governmental development organizations, donors, and

researchers together to work collectively in controlling trachoma. The World Health Assembly (WHA) adopted

resolution WHA51.11 in 1998, targeting the global elimination of trachoma as a public health problem. In

addition, with support from the Edna McConnell Clark Foundation and WHO, the SAFE strategy was created

to control trachoma through community-based interventions. In 2004, ICTC, a coalition of NGOs, donors,

academic institutions, and other partners, was created to support the GET2020 Alliance and to advocate for

the implementation of the SAFE strategy. The SAFE strategy stands for: Surgery to correct TT, the advanced,

blinding stage of the disease; Antibiotics to clear Ct infection; and Facial cleanliness as well as Environmental

improvement to reduce transmission.

Another important development was the finding that the oral antibiotic, azithromycin, taken once or twice

annually, is as effective in preventing chronic trachoma as six weeks of daily treatment with TEO, the previously

recommended therapy. In 2009, Pfizer Inc., manufacturer of Zithromax®, recommitted to supporting the

GET2020 Alliance goal of eliminating trachoma as a public health problem by the year 2020. Since the

beginning of the donation in 1998, more than 940 million doses of Zithromax® have been donated by Pfizer

Inc. and managed by ITI. The existence of the donation program has served to invigorate national trachoma

programs and reinforce global support for the elimination of trachoma. In 2016, WHO published the dossier

template for the validation of the elimination of trachoma as a public health problem. Between 2017 and 2018,

seven countries fulfilled the criteria to be validated by WHO to have eliminated trachoma as a public health

problem. In 2018, the global trachoma community celebrated three 20th anniversary milestones: The Carter

Center began its pioneering work in 1998; WHA 51.11 called for the elimination of blinding trachoma; and

Pfizer Inc. created ITI to lead the drug donation program. As of April 2021, 11 countries have been able to

submit their dossier and receive validation by the WHO as having eliminated trachoma as a public health

problem.

15 The Weekly Epidemiological Record published on 24 July 2020 previously stated that, in May 2020, trachoma was a public health problem in all or large parts of 46 countries; two countries within those 46 claimed to have eliminated trachoma, yet by July 2020 data corroborating those claims had not yet been validated by the WHO.

Appendix III

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TT and TF Thresholds for Disease Elimination

The achievement of the elimination of trachoma as a public health problem is defined by the WHO through

two proxy indicators:

1) a prevalence of TT “unknown to the health system” of <0.2% in adults ages ≥15 years (approximately

one case per 1,000 total population); and

2) a prevalence of TF in children ages 1–9 years of <5% in each (formerly) endemic district.

Through WHA reolution 51.11, trachoma can be eliminated as a public health problem through the

implementation of the WHO-endorsed SAFE strategy. The strategy consists of Surgery, Antibiotic distribution

at community level, Facial Cleanliness, and Environmental improvement. The surgery, or S component, should

be offered to any individual with TT that is diagnosed to benefit from the surgical treatment. The surgery

component also include case finding activities, which are recommended when prevalence of TT is ≥ 0.2%

among individuals who are ≥15 years old. The A, F, and E components of the strategy are recommended for

areas in which TF prevalence is ≥5% in children of ages 1-9.

To meet the criteria mentioned above, population-based prevalence surveys, amogst other activities, must be

conducted in districts (enumeration units) suspected of being endemic at baseline and then at specified intervals

after the start of interventions. Below are the success indicators and procedures often used to determine

whether a district or region has achieved thresholds for the elimination of trachoma as a public health problem:

TIS: Must be conducted at least six months after final planned MDA. If the TF prevalence threshold has been

met, the district enters a two-year hold period (no MDA required).

TT activities: If TF prevalence threshold is met, but not TT threshold, then the program must conduct case

searching and management activities.

TSS: At the conclusion of the two-year hold period, after the final impact survey, a surveillance survey is

undertaken. If TT and TF thresholds are met, then the district is considered as “transitioned” and no longer

warrants interventions. If thresholds are not met, then the district is re-enrolled in TT activities and MDA as

appropriate.

Appendix IV

The Power of Partnership: Achieving Success with Compassion and Joy The Twenty-Second Annual Trachoma Control Program Review

The Carter Center

March 22-23, 2021

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Monday, March 22

08:00 – 08:10 10 mins

Meeting Management & Welcome Ms. Debbie Jackson-Cole &

Ms. Kelly Callahan (Chair) Project Manager & Director, Trachoma Control Program

MYT & The Carter Center

08:10 – 08:20 10 mins

Welcome & Opening Remarks Ms. Paige Alexander, Mr. Jason Carter &

Dr. Kashef Ijaz Chief Executive Officer, Chair – Board of Directors &

Vice-President, Health Programs The Carter Center

08:20 – 08:25 05 mins

Goodwill Message Dr. Tedros Adhanom Ghebreyesus Director-General

World Health Organization

08:25 – 08:40 15 mins

Program Review Overview Ms. Kelly Callahan Director, Trachoma Control Program

The Carter Center

08:40 – 08:45 05 mins

Guided Mindfulness Meditation Ms. Kenya Casey Senior Associate Director, Overseas Operations

The Carter Center

08:45 – 09:00 15 mins

World Health Organization

Update & NTD Roadmap

Dr. Mwelecele Ntuli Malecela NTD Director

Department of Control of NTDs World Health Organization

09:00 – 09:30 30 mins

Destination Elimination, 20 Years

of Trachoma Programming in Mali

Professor Lamine Traoré National Coordinator, National Eye Health Program

Ministry of Health – Mali

09:30 – 10:00 30 mins

Niger SAFE Update Dr. Kadri Boubacar Deputy Coordinator, National Eye Health Program

Ministry of Health – Niger

10:00 – 10:15 Break

10:15 – 10:45 30 mins

Ethiopia SAFE Update Mr. Fikre Seife National NTD Program Coordinator

Ministry of Health – Ethiopia

10:45 – 11:15 30 mins

Amhara SAFE Update Dr. Hiwot Debebe Deputy Head

Amhara Regional Health Bureau – Ethiopia

11:15 – 12:00 45 mins

Persistence Focus Dr. Jeremiah Ngondi, Dr. Scott Nash &

Dr. Harry Pickering Senior NTD Advisor, Epidemiologist &

Dept. Pathology and Laboratory Medicine RTI, The Carter Center & UCLA

12:00 – 12:05 05 mins

Meeting Wrap-Up Ms. Kelly Callahan Director, Trachoma Control Program

The Carter Center

Appendix IV

The Power of Partnership: Achieving Success with Compassion and Joy The Twenty-Second Annual Trachoma Control Program Review

The Carter Center

March 22-23, 2021

64

Tuesday, March 23 08:00 – 08:10

10 mins Meeting Management &

Chairperson Announcements

Ms. Debbie Jackson-Cole &

Ms. Kelly Callahan (Chair) Project Manager & Director, Trachoma Control Program

MYT & The Carter Center 08:10 – 08:40

30 mins Sudan SAFE Update Dr. Balgesa Elshafie

National Coordinator for Trachoma Control Program Federal Ministry of Health – Sudan

08:40 – 09:10 30 mins

South Sudan SAFE Update Mr. Makoy Logora Director for Guinea Worm Eradication and

Director PC-NTDs Ministry of Health – South Sudan

09:10 – 09:25 15 mins

South Sudan: Face Washing

Qualitative Study

Ms. Angelia Sanders Associate Director, Trachoma Control Program

The Carter Center

09:25 – 09:35 10 mins

Health Campaign Effectiveness

Coalition

Dr. Kristin Saarlas Director, Health Campaign Effectiveness Program

Task Force for Global Health

09:35 – 10:00 25 mins

Photography Focus Dr. Fahd Naufal & Miss Cassidy Whitson Post-Doctoral Fellow & Health Comms. Specialist

Johns Hopkins University & Centers for Disease Control and Prevention (CDC)

10:00 – 10:15 Break 10:15 – 10:30

15 mins SWIFT Focus Dr. Jeremy Keenan

Director of International Programs Proctor Foundation

10:30 – 10:40 10 mins

International Trachoma Initiative

& Pfizer Update

Dr. Paul Emerson & Miss Julie Jenson Director, International Trachoma Initiative;

Interim Director, Children Without Worms & Director, Corporate Responsibility

Task Force for Global Health & Pfizer Inc.

10:40 – 10:50 10 mins

International Coalition for

Trachoma Control Update

Mr. Scott McPherson Senior Program Manager & Chair

RTI International & International Coalition for Trachoma Control

10:50 – 11:00 10 mins

Compassion & Interconnectedness

in Public Health

Dr. David Addiss Director, Focus Area for Compassion and Ethics (FACE)

Task Force for Global Health

11:00 – 11:05 05 mins

Meeting Wrap-Up Ms. Kelly Callahan Director, Trachoma Control Program

The Carter Center 11:05 – 11:20

15 mins Closing Remarks Dr. Kashef Ijaz

Vice-President, Health Programs The Carter Center

Program Review Participants Appendix V

Please note this list is not a full representation of all meeting participants, since several individuals might have been participating or watching in the same room or attending the meeting via our Youtube Stream. The names below represent are individuals who attended and registered their affiliations via the Zoom Meeting Platform.

65

Brazil Ms. Andreia De Pádua (MOH)

Ethiopia Mr. Adisu Abebe (ARHB)

Dr. Solomon Aragie (The Carter Center)

Mr. Zebene Ayele (The Carter Center)

Mr. Ambahun Chernet (The Carter Center)

Dr. Hiwot Debebe (ARHB)

Mr. Abebe Fisseha (The Carter Center)

Mr. Begashaw Hailemariam (The Carter Center) Dr. Fikreab Kebede (MOH)

Mr. Yemane Kejela (The Carter Center)

Mr. Berhanu Melak (The Carter Center)

Mr. Aderajew Mohammed (The Carter Center)

Mr. Birhanu Rita Nigussie (The Carter Center)

Mr. Eshetu Sata (The Carter Center)

Mr. Fikre Seife (MOH)

Mr. Ayalew Shiferaw (The Carter Center)

Dr. Zerihun Tadesse (The Carter Center)

Mr. Mulat Zerihun (The Carter Center)

Haiti Dr. Luccene Desir

Mali Dr. Abdoulaye Guindo (MOH)

Mr. Yaya Kamissoko (The Carter Center)

Mr. Sadi Moussa (The Carter Center)

Prof. Lamine Traoré (MOH)

Niger Prof. Abdou Amza (MOH)

Mr. Nassirou Beido(MOH)

Dr. Kadri Boubacar (MOH)

Mr. Mohamed Salissou Kane (The Carter Center)

Mr. Barmou Moudi (The Carter Center)

Nigeria Mr. Emmanuel Emukah (The Carter Center)

Mr. Emmanuel Miri (The Carter Center)

Dr. Obiageli Nebe (FMOH)

Mr. John Umaru (The Carter Center)

South Sudan Mr. Peter Mahal Dhieu Akat (Ministry of Water

Resources and Irrigation)

Ms. Lydia Banfield (The Carter Center)

Mr. Alfred Nurja (The Carter Center)

Mr. Makoy Samuel (MOH)

Ms. Katina Sommers (The Carter Center)

Mr. Jake Wheeler (The Carter Center)

Sudan Ms. Zeinab Abdalla (The Carter Center)

Ms. Maha Adam (The Carter Center)

Ms. Maymoona Ahmed (The Carter Center)

Mr. Khalafallah Alasad (FMOH)

Dr. Hamdan Ali (FMOH)

Dr. Nabil Aziz Awadalla (The Carter Center)

Mr. Atif Elamin (The Carter Center)

Dr. Nadia Elemam (FMOH)

Mr. Mazin Elsanosi (The Carter Center)

Dr. Balgesa Elkheir Elshafie (FMOH)

Dr. Amani Mustafa (The Carter Center)

Mr. Isam Mohammed Ali Zarroug (FMOH)

Abbott Ms. Suki McClatchey

CBM International Dr. Babar Qureshi (IEH Initiative)

Ms. Girija Sankar

Centers for Disease Control and Prevention (CDC) Dr. Paul Cantey

Mr. Ross Cox

Dr. Diana Martin

Ms. Cassidy Whitson

Conrad N. Hilton Foundation Ms. Melissa Dang

Mr. Robert Miyashiro

Crown Agents Ms. Atia Alatiaby

Ms. Aja Kuol

Ms. Kendra Palmer

Program Review Participants Appendix IV

66

ELMA Philanthropies Dr. Moe Assoum

Emory University Dr. Hope Bussenius

Dr. Deborah McFarland

END Fund Ms. Molly Anderson

FHI 360 Ms. Stephanie Palmer

Focus Area for Compassion & Ethics – Task Force for Global Health (FACE-TFGH) Dr. David Addiss

Francis I. Proctor Foundation at the University of California at San Francisco Dr. Jeremy Keenan

Health Campaign Effectiveness Coalition – Task Force for Global Health (HCEC-TFGH) Dr. Kristin Saarlas

Helen Keller International Mr. Steven Reid

Mr. Ouassa Sanogo

Ms. Cleo Stern

Mr. Toudja Tchouloum

IMA World Health Mr. Abdel Direny

International Coalition for Trachoma Control (ICTC) Ms. Aparna Barua Adams

Mr. Scott McPherson

International Trachoma Initiative (ITI) Mr. Menbere Alemu

Ms. Ana Bakhtiari

Dr. Paul Emerson

Dr. Teshome Gebre

Ms. PJ Hooper

Ms. Genevieve LaCon

Ms. Rosemary Pearson-Clarke

John and Kathleen Schreiber Foundation Ms. Molly Cullum

Johns Hopkins University Dr. Fahd Naufal (Wilmer Eye Institute)

Dr. Sheila West

Lions Clubs International Foundation

Ms. Gillian Gibbs

Dr. Patti Hill

Ms. Karen Kilberg

Mr. Brian Sheehan

Mr. Mama Tapo

London School of Hygiene and Tropical Medicine Dr. Esmael Habtamu Ali

Dr. Emma Harding-Esch

Neglected Tropical Diseases Support Center (NTDSC) Ms. Kira Barbre

Noor Dubai Foundation Mr. Omar Ba

Ms. Noora Elkouka

Dr. Mansur Rabiu

Onchocerciasis Elimination Program for the Americas (OEPA) Ms. Alba Lucia Morales

PATH Dr. Larry Slutsker

Pfizer Inc. Ms. Ayoola Abimbola

Ms. Niesha Foster

Ms. Julie Jenson

RTI International Ms. Clara Burgert-Brucker

Dr. Jeremiah Ngondi

Mr. Benjamin Nwobi

Program Review Participants Appendix IV

67

Sightsavers Dr. Michael D. Bejiga

Mr. Simon Bush

Dr. Mamadou Coulibaly

Dr. Boubacar Dicko

Ms. Sarah Huntbach-Noel

Ms. Cristina Jimenez

Ms. Michaela Kelly

Mr. Tom Millar

SOLE Dr. Jean-Pierre Brechet

The Task Force for Global Health Ms. Kira Barbre

Mr. Bill Nichols

University of California – Los Angeles Dr. Harry Pickering

University of North Carolina – Chapel Hill Ms. Emily Gower

University of South Florida Dr. Mahmooda Khaliq Pasha

United States Agency for International Development (USAID) Mr. Aryc Mosher

World Health Organization (WHO) Dr. Laxmikant Chavan

Dr. Nzuzi Katondi

Dr. Amir Kello

Dr. Mutale Senkwe

Dr. Anthony Solomon

The Carter Center Ms. Paige Alexander

Ms. Laurie Baxley

Ms. Nina Benard

Ms. Jaymie Bromfield

Ms. Kelly Callahan

Ms. Becky Carter

Ms. Kenya Casey

Mr. Drew Deathe

Mr. Don Denard

Ms. Andrea Echols

Ms. Cassandra Grant

Ms. Emily Griswold

Ms. Nehad Hamed

Dr. Karen Hamre

Ms. Madelle Hatch

Dr. Kashef Ijaz

Ms. Nadha Illikkal

Ms. Molly Ison

Ms. Keya Jacoby

Ms. Kim Jensen

Mr. Jim Kavanaugh

Mr. Curtis Kohlhaas

Ms. Nicole Kruse

Mr. Phong Le

Ms. Amy Macklin

Mr. Ryan Mathura

Ms. Abby Miller

Ms. Sarah Mueller

Dr. Scott Nash

Ms. Mindze Nkanga

Dr. Greg Noland

Mr. Andrew Nute

Dr. Frank Richards

Dr. Angelia Sanders

Ms. Alethia Sanon

Ms. Vanessa Scholtens

Ms. Janet Shin

Ms. Courtney Gale Simmons

Ms. Rennie Sloan

Ms. Emily Staub

Ms. Shandal Sullivan

Mr. Marc Tewari

Mr. Adam Weiss

Ms. Bryony Whitelaw

Mr. Craig Withers

Ms. Sara Wom

Ms. Sarah Yerian

Ms. Sarah Yoss

Documents

The Power of Partnership: Achieving Success with Compassion